Filing # 68107654 E-Filed 02/16/2018 05:45:45 PM

IN THE SUPREME COURT OF FLORIDA

NO. SC-_________

______________________________________________

ERIC SCOTT BRANCH,

Petitioner,
v.

JULIE L. JONES, SECRETARY,

FLORIDA DEPARTMENT OF CORRECTIONS
RECEIVED, 02/16/2018 05:48:30 PM, Clerk, Supreme Court

Respondent.
______________________________________________

EMERGENCY PETITION TO INVOKE THIS COURT’S ALL WRITS

JURISDICTION TO DIRECT THE DEPARTMENT OF CORRECTIONS TO
PROVIDE ATTORNEY ACCESS PRIOR TO AND DURING THE
EXECUTION
______________________________________________

Stacy Biggart Billy H. Nolas

Florida Bar No. 89388
Kathleen Pafford
Florida Bar No. 99527
Assistant Capital Collateral
Regional Counsel – North
Office of the Capital Collateral
Regional Counsel – North
1004 DeSoto Park Drive
Tallahassee, Florida 32301
(850) 487-0922
Stacy.Biggart@ccrc-north.org
Kathleen.Pafford@ccrc-north.org
Florida Bar No. 806821
Chief, Capital Habeas Unit
Kimberly Sharkey
Florida Bar No. 505978
Attorney, Capital Habeas Unit
Office of the Federal Public Defender
227 N. Bronough Street, Suite 4200
Tallahassee, FL 32301-1300
(850) 942-8818
billy_nolas@fd.org
kimberly_sharkey@fd.org

Counsel for Appellant

 PRELIMINARY STATEMENT

An Appendix is attached to this Petition. The following symbol will be used

to designate references to the Appendix: “A. ___”.

JURISDICTION

This Court has jurisdiction in this matter pursuant to the Florida Constitution

Article V § 3(b)(7)-(8). Article V § 3(b)(7) gives this Court the authority to “issue

writs of prohibition to courts and all writs necessary to complete the exercise of its

jurisdiction.” In Williams v. State, 913 So. 2d 541 (Fla. 2005), this Court stated that

the “all writs provision . . . operates as an aid to the Court in exercising its “ultimate

jurisdiction,”’ as opposed to operating as a separate and distinct source of

jurisdiction. Additionally, this Court has the authority to “issue writs of mandamus

and quo warranto to state officers and state agencies.” Fla. Const. Art. V § 3(b)(8).

This court has construed a writ of mandamus to be the “appropriate vehicle for

addressing claims of unconstitutionality ‘where the functions of government will be

adversely affected without an immediate determination.”’ Allen v. Butterworth, 756

So. 2d 52, 54-55 (Fla. 2000) (quoting Division of Bond Finance v. Smathers, 337

So. 2d 805, 807 (Fla. 1976).

The Department of Corrections (DOC) is substantially inhibiting the functions

of government by denying Petitioner’s limited and specific requests related to his

pending execution. These unjustified denials adversely affect the functions of

government and risk allowing Petitioner’s execution to proceed in violation of the

Eighth Amendment.

Since Petitioner is scheduled to be executed at 6:00 p.m. on February 22,

2018, it is necessary for this Court to issue an immediate determination.

REQUEST FOR ORAL ARGUMENT

The DOC’s refusal to allow Petitioner safeguards to ensure his execution is

carried out in a manner that complies with the Eighth Amendment’s prohibition

against cruel and unusual punishment substantially affects his ability to enforce his

Constitutional rights. Petitioner requests oral argument on this Petition to allow for

a full discussion of this issue.

FACTUAL BACKGROUND

Eric Branch’s execution is scheduled for 6:00 p.m. on February 22, 2018. On

February 1, 2018, counsel for Petitioner sent a letter to Warden Barry Reddish,

warden of Florida State Prison, requesting the following: 1) that Petitioner’s

designated legal witness be allowed access to a writing pad and pen during

Petitioner’s execution; 2) that Petitioner’s designated legal witness be allowed

access to a telephone before and during the execution process;1 3) that Petitioner be

1Petitioner made clear that the requested telephone need not physically be with the
witness, only that the witness be able to access the telephone in the event the
execution went awry.

2
afforded a second witness to his execution; and 4) that one of Petitioner’s witnesses

be allowed to view the IV insertion process.2 (A. 001-002).

On February 6, 2018, counsel for Petitioner sent Warden Reddish a follow-up

e-mail, informing him that Petitioner’s spiritual advisor would not be attending

Petitioner’s execution, thereby opening a witness chair. Petitioner requested again

that a second witness from his legal team be able to occupy this seat. (A. 003).

On February 15, 2018, counsel for Petitioner received a letter from the DOC,

granting Petitioner’s request that his designated witness be allowed access to writing

implements and denying all other requests. The DOC provided no basis for its

decision, legal or otherwise. (A. 004-005).3 This Writ follows.

ARGUMENT

This Court should direct DOC to comply with Petitioner’s three remaining

requests: 1) allow for a second witness to observe his execution, 2) allow at least one

of the witnesses access to a telephone, and 3) allow at least one of the witnesses to

observe the IV insertion process. Failure to do so amounts to a denial of due process

and access to the Courts, preventing Branch, and other similarly situated inmates,

from raising and proving that his execution procedure violates the Eighth

2Counsel for Petitioner suggested to DOC a way in which this could be done, yet
still protect the identity of the execution team members.

3The letter also references DOC’s denial of Mr. Branch’s request to waive an
autopsy, but Mr. Branch is not challenging that refusal at this time.
3
Amendment. DOC’s refusal of these requests denies Branch a fair opportunity to

protect his Eighth Amendment rights because it deprives him of the necessary

information and access to challenge whether his execution is constitutional. As such,

he is being denied a “basic ingredient of due process.”: “an opportunity to be allowed

to substantiate a claim before it is rejected.” See Ford v. Wainwright, 477 U.S. 399,

414 106 S. Ct. 2595, 2604(1986)(plurality opinion)(internal quotation marks

omitted).

This Court recently denied Mr. Branch’s public records requests relating to

the expiration dates of the lethal chemicals stating that it “will presume ‘the DOC

will act in accordance with its protocol and carry out its duties properly. This same

presumption would extend to presume that the DOC will obtain viable versions of

the drugs it intends to use and confirm before use that the drugs are still viable, as

the protocol requires.’” Branch v. State, --- So.3d. ---, 2018 WL 879079

(Fla.)(emphasis in original)(citing to Muhammad v. State, 132 So.3d at 206).

Affording DOC this presumption while at the same time granting DOC

unfettered discretion to limit attorney access and decrease transparency of the

execution process poses an unacceptable and unconstitutional risk of an execution

that runs afoul of the Eighth Amendment.

As this Court is aware, Florida has a troubled history with botched executions,

from a repeatedly malfunctioning electric chair to the 34 minute execution of Angel

4
Diaz in 2006, which “raised legitimate concerns about the adequacy of Florida's

lethal injection procedures and the ability of the DOC to implement them.”

Lightbourne v. McCollum, 969 So.2d 326, 345 (Fla. 2007).

Florida has been through numerous protocol changes since the Diaz botch,

and instead of increasing transparency in the pre-execution and execution process,

DOC has taken active steps to reduce transparency. In 2013, the first inmate

executed using the Midazolam Protocol was William Happ. Shortly after the

administration of midazolam, which was supposed to have anesthetized him such

that he would not feel the excruciating pain that was about to follow from the second

and third drugs, DOC performed the “consciousness check” required by their

Protocol to ensure that he was unconscious. However, witnesses observed

movement by Mr. Happ after the consciousness check. These movements evidence

insufficient anesthetic depth before the administration of the painful second and third

drugs. (A. 006 - 017). As a result, and according to Dr. Lubarsky, “the worst

possible death experience was delivered – the paralytic effectively burying the

patient alive, whose agony at being aware but unable to draw a breath was only

brought to a horrendous end through the agonizing delivery of a caustic chemical

surging through his body.” (A. 014). Specifically, after Mr. Happ’s execution

Warden Cannon decided to tweak the Midazolam Protocol by adding the trapezius

pinch to ensure the inmate was unconscious. (A. 067).

5
The trapezius pinch involves gripping and pinching the trapezius muscle in the

inmate’s shoulder. (A. 060).

Aware of the shortcomings of midazolam as an anesthetizing agent, DOC then

adopted measures designed to actually prevent the inmate from moving, which

would evidence lack of consciousness and/or prevent witnesses from observing any

movement by the inmate. Specifically, during the execution of Mr. Darius

Kimbrough on November 12, 2013, which was the first execution after Mr. Happ,

DOC covered him from his shoulders to his feet with a white sheet that appeared to

be tented over his body instead of just draped, such that witnesses could not observe

any movement of Mr. Kimbrough under the sheet. (A. 084-087). This was different

from the previous executions where the sheet was merely draped over the inmate

and witnesses could see the chest of the individual rising and falling during the

execution. DOC further tweaked its actual execution procedures, though made no

changes to the written protocol, by beginning to tightly bandage the hands of the

inmates. (A. 084-087).

DOC changed its protocol again in January of 2017, using a completely new

three-drug protocol, the Etomidate Protocol. The execution of Michael Lambrix was

carried out using the Etomidate Protocol, and that is the same protocol expected to

be used for the execution of Eric Branch.

6
 Though it is unclear precisely when, at some point since the Diaz execution, DOC

has altered the position of the body of the prisoner in the execution chamber. (A.

088-090, filed in State v. Hannon, SC17-1837, ROA p. 519-522.) “Mr. Lambrix

was not placed in the same position as Mr. Diaz. Where Mr. Diaz was perpendicular

to my position in the front row giving an unobstructed view of his face; right side of

his body, including the insertion site; and right hand, Mr. Lambrix was strapped to

the gurney with his feet pointed directly towards me.” (A. 089). “Mr. Lambrix was

covered by a sheet and his hands and fingers were completely covered up to his

wrists with what appeared to be a giant mitten making observation of his hands

impossible. There was nothing completely covering Mr. Diaz’s right hand during

his execution leaving his hand partially observable for the witnesses…And, instead

of a direct unobstructed view of Mr. Lambrix’s face, like I had of Mr. Diaz, I had to

look over Mr. Lambrix’s feet and his covered body in order to see his face.” Id. The

attorney witness was also without access to his cell phone, even though the execution

had been delayed. “From 5:30 p.m. to 9:30 p.m….I was unable to contact Mr.

Lambrix’s legal team as I had no access to my cellular phone. However, I observed

as least one Florida Department of Corrections’ employee who was also a witness

to the execution using a cellular phone during the time the witnesses were confined

to the chapel.”). (A. 088).

7
 Unlike in Florida, in other states where lethal injection executions have gone

awry, those states have taken steps to increase transparency and attorney access. For

example, after the botched executions of Romell Broom and Dennis McGuire, the

State of Ohio increased access and transparency. The State of Ohio specifically

allows for the prisoner to “request that one or two attorneys attend the execution.”

(A. 094). The protocol also provides that “[i]f the prisoner chooses to have his or

her counsel as a witness, at all times after counsel enters the witness room, counsel

shall have free access to the phone near the entrance door of the Death House.” (A.

103) (emphasis added). Finally, the Ohio protocol directs that while the curtain in

the execution chamber closes, the “closed-circuit camera shall remain on to allow

the witnesses to view the establishment of the IV site(s).” Id.

Similarly, after the botched execution of Joseph Wood, Arizona increased

access and transparency in its execution procedure. (A. 110-145). Arizona allows

for up to 3 witnesses from the legal team, and there is no requirement that the

witnesses be an attorney.

In the event that the inmate wishes to designate one or more of their
attorneys or other members of their legal team (not to exceed a
cumulative three persons) to witness the execution, then the inmate
shall identify these witnesses twenty-one days prior to the execution,
and these witnesses shall sign and timely submit an Official Witness
Agreement (Form 710-6), whereupon the Director shall invite these
witnesses to attend the execution in accordance with section 710.10,
1.2.1.1 of this Department Order.
(A. 120).
8
Further, Arizona explicitly allows the witnessing attorney immediate access to a cell

phone:

In the event the inmate has designated one of his attorneys to witness
the execution, temporary office space will be provided for the inmate’s
counsel in the Administration Building during the scheduled day of
execution. One attorney and two additional members of the legal team
may be permitted to remain in the office space during the execution.
The inmate’s legal team will be permitted to bring into the temporary
office space one mobile phone, one tablet, and one laptop. While the
attorney witness is in the witness room, a member of the Witness Escort
Team shall hold one mobile phone designated by the attorney, to be
made available to the attorney in exigent circumstances. The mobile
phone may not be used inside the witness room.
(A. 127).
The Arizona protocol further mandates that witnesses view the IV insertion process:
Existing closed-circuit monitors will allow witnesses in the designated
witness room to observe the IV Team’s vein assessment and placement
of IV catheters in the inmate. In addition, the audio feed from the
overhead microphone will be turned off following the IV Team’s
assessment and placement of IV catheters. 11. A camera will be focused
on the area in the chemical room in which syringes are injected into the
IV line, and existing closed-circuit monitors will allow witnesses in the
designated witness room to observe the administration of the lethal
injection drug(s), including the administration of additional or
subsequent doses of the drug(s). All cameras and monitors shall be
placed in such a manner so as to ensure and preserve at all times the
anonymity of all personnel involved in the execution process.
(A. 141).
These procedures in Ohio and Arizona, who like Florida, have a history of

botched executions, allow for an increased transparency in the process, while at the

same time balancing the safety, identity, and security of DOC personnel and other

9
witnesses. Counsel for Mr. Branch has made identical requests to those that have

been established in Ohio and Arizona. DOC flatly refused these requests, offering

no justification or reasoning. (A. 004-005).

To ensure adequate access to the courts, it is necessary to have at least two

attorneys present at the viewing—one who can access a phone, and one who can

continue to monitor the execution should phone access be necessary. By preventing

witnessing counsel adequate phone access—indeed, any phone access—during the

execution, DOC’s policy violates Branch’s right of access to the courts. Further, by

refusing to allow a member of the legal team to witness the IV insertion process,

DOC is actively preventing Branch from bringing an Eighth Amendment challenge

that would arise after the execution process begins yet prior to the flow of lethal

chemicals that will cause death. Such a violation would serve as a basis for a stay

of execution.4 If DOC has difficulty in achieving venous access, and it either takes

an unusually long time with multiple attempts to locate a vein, and/or requires a

painful cut-down procedure to be used, Mr. Branch has no way of communicating

his pain and suffering to his counsel, in violation of both his Sixth and Eighth

Amendment rights.

4In fact, this is what happened in Ohio with the 2009 attempted execution of Romell
Broom, and more recently in the 2017 attempted execution of Alva Campbell, which
was halted after approximately 80 minutes of attempting venous access.
https://www.nytimes.com/2017/11/15/us/ohio-execution-alva-campbell.html (last
visited February 15, 2018).
10
 This Court should exercise its broad discretion and direct DOC to comply with

Mr. Branch’s specific and limited requests. The privilege of being granted the

assumption that an agency will faithfully carry out its duties while exacting the

highest possible penalty on a Florida citizen comes with the responsibility that the

agency create as much transparency as possible to prevent an unconstitutional

execution. This Court should grant the Writ.

Respectfully submitted,

/s/ Stacy Biggart /s/ Billy H. Nolas

Stacy Biggart Billy H. Nolas

Florida Bar No. 89388 Florida Bar No. 806821
Kathleen Pafford Chief, Capital Habeas Unit
Florida Bar No. 99527 Kimberly Sharkey
Assistant Capital Collateral Florida Bar No. 505978
Regional Counsel – North Attorney, Capital Habeas Unit
Office of the Capital Collateral Office of the Federal Public Defender
Regional Counsel – North 227 N. Bronough Street, Suite 4200
1004 DeSoto Park Drive Tallahassee, FL 32301-1300
Tallahassee, Florida 32301 (850) 942-8818
(850) 487-0922 billy_nolas@fd.org
Stacy.Biggart@ccrc-north.org kimberly_sharkey@fd.org
Kathleen.Pafford@ccrc-north.org

11
 CERTIFICATE OF SERVICE

I hereby certify that on February 16, 2018, the foregoing was electronically

served via the e-portal to Ryan Padgett, Assistant General Counsel, Florida

Department of Corrections, (Ryan.Padgett@fdc.myflorida.com); Charmaine

Millsaps, Assistant Attorney General, (Charmaine.Millsaps@myfloridalegal.com),

and Lisa Hopkins, Assistant Attorney General (Lisa.Hopkins@myfloridalegal.com)

and capapp@myfloridalegal.com

/s/ Stacy R. Biggart

Stacy R. Biggart

CERTIFICATE OF FONT

This is to certify that the foregoing Initial Brief of Appellant has been

reproduced in Times New Roman 14-point font, pursuant to Rule 9.100(1), Florida

Rules of Appellate Procedure.

Respectfully submitted,

/s/ Stacy R. Biggart

Stacy R. Biggart
 IN THE SUPREME COURT OF FLORIDA

STATE OF FLORIDA
CASE NO.
v.

ERIC SCOTT BRANCH,

Defendant.
______________________________/

APPENDIX TO WRIT OF PROHIBITION

 INDEX TO APPENDIX

1. Letter from CCRC-N to Warden Reddish dated February 1, 2018….001-002

2. E-mail from CCRC-N to Warden Reddish dated February 6, 2018 ……..003

3. Letter from DOC to CCRC-N dated February 15, 2018……………004-005

4. Expert Declaration of Dr. David Lubarsky…………………………..006-017

5. Transcript from evidentiary hearing in State v. Paul Howell………..018-083

6. Affidavit of Richard Kiley………………………………………….084-087

7. Affidavit of Neal Dupree…………………………………………….088-090

8. State of Ohio execution protocol…………………………………….091-109

9. Arizona Department of Corrections execution protocol…………..…110-145

Telephone:
(850) 487-0922
ROBERT F'RIEDMAN
CAPTTALæLIATERAL REGIOMLæLTNSEL
}.¡ORN.IERNRECICÌ{

OFFICE OF THE
CAPITAL COLLATERAL REGTONAL COUNSEL
NORTHERN REGION
1004 DeSoto Park Drive
Tallahassee, FL 32301

February 1,2018

V/arden Bany Reddish

Florida State Prison
P.O. Box 800
Raiford, FL 32083

Dear Warden Reddish,

Our office has been appointed to represent Eric Scott Branch in his post-conviction
proceedings, which necessarily include the death warrant stage we now find ourselves in. As
õounsel for Mr. Branch, we are duty bound to witness the execution, currently scheduled for
Thursday, February 22,2018 at 6:00 p.m. We have a number of requests regarding the
witnessing of Mr. Branch's execution that we hope you will consider.

Our first request is to allow our designated witness to bring a writing pad and pen into the
observation room during the time the execution is taking place. It is our understanding that the
members of the press present at executions have been allowed to have a notepad and writing
instrument to record their observations as they take place. Additionally, we have been informed
that the FDLE agent, whose obligation it is to record his/her observations, also has access to
writing implementations to records their observations. V/e would request that whoever witnesses
the execution from our office be afforded the same access to writing materials as the press and
FDLE.

Our second request is that a witness from the legal team be allowed access to a phone
before and during the execution process. This would allow the witness to be apprised of the
most up to date information regarding Mr. Branch's case. Additionally, should the execution go
awry, it could be necessary for the witness in the observation room to contact the courts and/or
legal team to stop the execution. We certainly understand that cameras are not allowed in the
observation room, and we have no intention of taking pictures, nor are we requesting to do so,
however, in the event an execution goes badly it is impossible for members of the legal team to
take any action since the legal witness has no access to any communication device. It is also
problematic that the witness from the legal team cannot remain in contact with attorneys outside
ihe grounds of the prison during periods of delay. Communication between members of the team
during this time is extremely important when critical legal decisions are being made and that can

001
only occur when access to a cellular device is allowed. The phone does not have to be physically
on the witness, the witness just needs to be able to access the phone if they need to.

Along those same lines, our third request is to allow our offrce an additional witness,
bringing the total of legal team witnesses to two. In the event that Mr. Branch's execution goes
wrong, the presence of two legal witnesses will allow for one witness to leave and promptly alert
the legal team and courts, while the other witness remains in the observation room.

Finally, our fourth request is that you allow one of our witnesses to be present and/or
have unobstructed viewing during the IV insertion process. As Iom sure you're aware, this is a
critical moment during the lethal injection process and any difficulties achieving venous access
andlor errors in obtaining proper access would cause Mr. Branch severe pain, in violation of the
Eighth Amendment's prohibition against cruel and unusual punishment. We are mindful that the
identities of the execution team are kept secret under the law, but perhaps the IV insertion
process can be observed via a video that is narrowly focused on the insertion sites, and as such
would continue to shield the identities of the execution team members. Additionally, the
attorney witness is an officer of the court, and therefore bound not to reveal the identity of any
team member.

We appreciate the solemnity of this process, however, as legal representatives of Mr.

Branch, we feel a responsibility to him, and others similarly situated, to be able to communicate
effectively within the legal team before and during his execution. We hope you will respond
favorably to our requests and we look forward to hearing from you.

"ffifu,p^
Kathleen Pafford
Assistant CCRC-N
Co-Counsel for Mr. Branch

002
2t16t2018 Capital Collateral Regional Counsel - North Mail - Requests regarding Eric Branch execution

GMail
u¡d,rxr¡trlr
Kath leen Pafford <kathleen.pafford@ccrc-north.org>

Requests regarding Eric Branch execut¡on

Kathfeen Pafford <kathleen.pafford@ccrc-north.org> Tue, Feb 6,2018 at 11:31 AM
To: Barry.Reddish@fdc. myfl orida.com
Cc: Stacy Biggart <stacy.biggart@ccrc-north.org>, "Godwin, Shawn" <shawn.godwin@fdc.myflorida.com>

Hello again,

I just wanted to add that we found out today Mr. Braneh's spiritual adviser will not be attending the execution. Our
understanding is that this leaves open one witness chair, which, as stated in our previous written request, we'd like to fill
with a second witness from the legal team. lf you have any questions, please feel free to contact me.

Thank-you,
Kathleen Pafford
lQuoted text hiddenl

003
https://mail.google.com/mail/u/0/?ui=2&ik=0babf91d19&jsver=9CtlOcfiWQ."n.*u¡"r¡v=pt&msg=1616bfs02febd42b&search=sent&siml=l6l6bf502febd42b 111
 FLORIDA Govcrnor

DEPARTMENT of RICK SCOTT

CORRECTIONS !ìccrelary

JULTE L. JONES

50 I Suuth L'ul houn Strcct,'l'ul lahasscc, l"L 32399 -25Af) http://rvrvrv.dc.stûte, ll. us

February 15,2018

Kathleen Pafford
Assistant CCRC-N
1004 DeSoto Park Drive
Tallahassee, FL 32301

l)ear Ms. Pafford,

'l'he F'lorida l)epartment of Corrections (fDC) is in receipt of your letter dated February
l, 2018 regarding your request to FDC to waive several of the procedures in the January 4,2017
lethal injcction protocol (protocol). To summarize, you are requesting the following: a writing
pad and pen during the execution, access to a phone during the execution, an additional witness
(to be designated by CCRC), and to witness the IV insertion process. In conjunction with
rWarden l{eddish, the Offrce of the General Counsel has reviewed each of your requests. We

have no objection to CCRC's designated witness bringing a writing pad and a pencil.

FDC must respectfully decline your remaining three requests. The procedures in the
protocol werc developed from extensive discussion by FDC both at the Central Office and at the
institutional level. As stated in the certifïcation on the frrst page of the protocol, FDC's foremost
objective is a humane and dignified death. In order to ensure F'DC complies with its statutory
duties pursuant to Chapter 922,Florida Statutes and to maintain the security of our institutions,
FDC must adhcre strictly to the procedures in the existing protocol and will only waive these
procedures in exceptional circumstances. FDC has previously denied requests similar to those in
your letter.

It is F'DC's understanding that your client would like to waive the post-execution
autopsy. Section 922.11(3), Fla. Stat. provides:

(3) 1'he body of the executed person shall be delivered to the medical examiner for an
autopsy. AIIer completion of the autopsy, the body shall be prepared for burial and, if
requested, released to relatives of the deceased. If a coffin has not been provided by
relatives, the body shall be delivered in a plain coffin. If the body is not claimed by
relatives, it shall be given to physicians who have requested it for dissection or to be
disposed of in the same manner as are bodies of prisoners dying in the state prison.

004
'fo comply with the above statute, the January 4,2017 lethal injection protocol provides at
Specific Procedure ( I 3)(e):

(e) the inmate's body will be hansported by the hearse attendants to the medical
examiner's ofüce in Alachua County for an autopsy.
'['he language in s. 922.11(3), F.S. in unambiguous and, through the use of the word "shall,"
requires FDC to deliver the body of the executed inmate to the medical examiner's office for an
autopsy. Additionally, section 406.1l, Fla. Stat., requires that autopsies be performed on any
individual who dies in "any prison or penal institution." {j 406.1 I (l)(a)6., Fla. Stat. Because the
autopsy requirement is in statute, FDC has no discretion with regards to the performance or
waiver of an autopsy in this matter. Further, FDC cannot waive the provision relating to
autopsies in the protocol as it would create a conflict with the existing statute.

Sincerely,

stant General Counsel

*INSPIRING SUCCESS BY TRANSFORMING ONE LIFE AT A TIIII|E *

005
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006
Case 3:14-cv-01149-MMH-JBT Document 14-5 Filed 12101/14 Page 3 of 70 PagelD 422

to,adÈquatfrly m{¡irttäir ûnös-theüq.dcpth. ¡n'a o-ljnioattetttng I a¡n a r.ecurin-g'autltor of'the

öhaptcr on int¡hv@ous inductiqn agenls in qur qpecialty':s prirnary authoritative te¿tbook

(Miller's Anesthesia).

3. I h¿iy€-publishcd poe,r i:eviewed arfi.g,lcô:o¡ tcth*l injectffi ineludÌ¡g''the çnly rçioutific,

ptipel thrt êvaluatpd availab!ç,medicål data" and h¿vc s¿rved,a*an ç¿{pttrt wiffess iin leüral

injectìon litigation in sevual stafus'inÇludingìn Aloba,ma in the ç¿so oÊ Arthttt v, Tfui¡nas,

674 F3d 1257 (tlrh Cir. 2þ12)'. I þave also servad as an c¡(pert witnass in cases in Ohio,

Tennessee,. and PJorlda, I testifrçd at,a limitcd evidentiary hearÍng in tht Juqn Cal-'lps

Chavez c.ase before the FJonorable Judge D¡vis in this Fedemt Distriet Court on Februaty

5,2A14,3:14-cv-l l0-J-39JBT. A cument oopy of my ømptete CV is att¿chçd to this

Deolaration as Exhibit l.

4. I hav.ç becn a.iked by Plaíntiff to. rcvierv Deftndants' r'Exæution by Lethal trp'ootió-n

Procedurçsir deted:Septenrber 9.,,2013'(,I{øoinafter.Mldaaolam P.rotocol) dnd t0 addfcssthc

sûitab,ilþ of nridazolam as ara anrsthetic in a thrceidnrg lethal iUiaCtion pIotrilÖJ. ,l have.

been æked to opine whetfter the usp of midazolam for this ¡ruçose oreates.it sbstantia!

risk ofrserjous, hatm to Flaintiff.

5. tn formul4fing my opiníon, I have revicwed:

'a. The Midazo-lâm Prolocol

b, Dcfendants''piior pJoloeoJ, dated Scptember 4; 2012n which utilizcd pentcrbarbitâl

aS the {irsf drug in the t}iree-drug protoeol

007
Case 3:14-cv-01149-MMH-JBT Document 14-5 Filed 12101¡|14 Page 4 olTO PagelD 423

ô, ByewÍtross pness r€ports of the o:rtoutions sf,Willlam II*pp,

"Aska¡l AbrlUlldr

Muhamruad, and Juan, Carlos Chavezl

d. Thc Affrdavit of Richard Kiley, EsE" tvhç hæ Ob-¡ervd- thç axçputian¡ of lvl'trt¡n

Grossman, Darius Ivtlark Kirno'rough, and Eddie WayncDariis

e. The test¡mony of Er. Mark Heath, Dr. Roswe!!Lce Evans,,and fEt¿n InSpeotqÍ

Jonathsn Feltgen from the Ftodda çtate oircuit cÒúrl praçeèdingS inigfa¡e u'$sktri

Abdultøh M.Tthanma¿l

f, FDLE logs fio-m thç,rniæqtïons .Ðf lü-illism Happ" Àskari Âbduliah Muhammod,

Þarius'Mark Ki¡nbrcggbr,¡4¡¡ ëarlos Çh¿vez, Palil Hbrroll, Rohert Henry

g. Two letters fioil Ìlospira,. thç mirtufacturer 0f t¡ìdszolâm, i¡rdicating the

unsuitability of midazolrrn fb¡ use in e lettrat itr¡atrtiùi'l

h. Exeoution logs and èyewitnes's reporn,from the Joseph Wood execufion in. Ari'¿ona

i. Execution logs, autopsy report, and Deparnnent of Puhlio Safcty Repor,t dated

Seþtenber 4,2014 fi'om the Clayton Lookett e,rpcution in Olclahorn¿

6. Since my teçtimony in the Ciravaz case, there have been tlvo additional problematic
exæutio¡s nàtionwidc nsing,midtuolarn * Cla¡on Lockett in Olclahoma and Jbscph Wood

in Arìzo¡ra Thcse, two e¡æputions¡ part'icularly the Joseph rübod ext¡cutibn, provido

obþetive scientif¡c svidçlrce that mldasolam has a .ceiling'effeot, and fhat no a¡nount of

1.f¿e Brendan FarringÊon, îla, Exe(iute.r.rnan for lllinory wotlqn's l-98ó mwdet; Tamp4 Tribune
(Octobër 15,.20 I 3) alailable qt
citus.ço-!rng:{nurder-201 3 I 0 t5/; ttti¡losl Faur qnÐêsthRov,
fwnate Executed, The Gainesvills Sun 712014) gvailable at
trlVêavel ¿¡n¿l David. Oveile,
Juan Carlo.c Cltæ¡cz exe al ed þt nur&r oJ.Jirwtgt tzr 20'14)
availaþle, dl
ieiccts.html

008
Case 3:14-cv-01149-MMH-JBT Document 14-5 Filed tZJOtlt4 Page 5 of 70 PagelD 424

rnidazolam is, suffisíent to guarantee.Plaintiff w.ill be'insensate for ths achninjstrstionof ûho

seoond.snd ihird drugs called for in Defendants' Protocol.

7, I rendered this same opinion .in the Ch¿vez caso, basod on fi¡y ÊstraÞöletion fto. rn animal

studipp a¡d w,hat is known about tþg.sciençe behind how tåp:dr¡€ rworkg,Õn.nÐèp-tors ln

thç b¡An. H,orryever" in €havg¡ JudgeD¿vís'ul(.ìnral,ly:rgicctcd rny n'p,inrcu ++.bçing.too

sl.¡e0-uiafiveslnoe'I readily a -rnitted thut U.ec*iuse fhec,had:þ,eclrJ¡o"¿xBrri¡ng$_lipn hmùglls

,in tbudoss¡ calted for by D¿fqn&.ntsi p¡otdeol,lhsrçw.qs,¡OlftçraHi.ç:qù-O¡rt ho.rN,lougþliqh

a dOçe would [ast; of wheth.ei fhè dOsè would actu4lly supplêbs coÍ]SöiÕusrìgss adéquafely

to prevent pcin associated witli a causTic chernicr¡l injcctiolr or a foelïng of str.ffocation.by

the Plaintiff l{owever, I opined, b.ased on what was lcnown, thàt rbidazolårtr Ìtad a æilìng

effect, whjch was one of severâl reasons it was an unsuitable ancsthotiq as thö first drugjn,

a thrcc drug proto.col aÉd crsâtcd a sori¡sus risk of s'ubstântial Þain fto'¡n tlro ad¡niäisaatìon

ofthe second and,third drugs.

8. IntheJoseph'lVoodexeeudon,whichtook,ncarlytwohounslocornþlótc,ihswåsgivén'?$0,

rng of rnidazolame t5Orng more than, is c¿lled for.i¡t Defend,ants' protoool.

9, T'tiis experimertal'execution nswoffers definitivcss:ientific;proofftat Defendantcl S0û¡ng

dosage will noi rapidly or r'eliably. produce'unconsgiousness and ftrther supports my

origlnal opinion drat,ûrerc is acelling ef.fect with midazolam and,that hilher dosos ofthe
dtug do not equøte to a deeper level of,rmoonsciousnsss.

IQ. Itr,a olinica{ setting; the p-utpoæ,of ânesthesi$ is'ts rcñder,apa¡thnt lnsensate'to..tho cffcots

of a pnr*posed intcrvcrrtion¿ When a gcneral anesthetlo ie utít:ized, indl¡etion and

¡naintenance ofUnc9rtsciousne$s: alrd l¿ek of:r€sponsiveness to" noxious stimuli is the goal

and expected outcÕmo.

009
Case 3:14-cv-01149-MMH-JBT Document 14-5 Filed 1?01/14 Page 6 of 70 PagelD 425

I I . Midazolam is not intended for use as s totûl ançsthqric,i Ïfuorvr undpr fic tr¿de naË¡e

Versed, il is tlie shotest acting o-enzodirøgpine sn üe mmtceti

12. Benzodiauqp,lnps Aro,¿ cf¡Ss of;d¡ugç urùich arqp¡n{rily for,treatjn$qû¡(iety,

uSod TT¡py

'ireludç dt$gp suöh.ag Valit¡n,

At¡vaft aird Xa¡ær. In çlinicai use; nridazola¡l¡ is.rypiÇâll]1

administe¡ed prior'to rhe in(iuotion sf'ênesthosia in purgical sÕtti.ltgs to tr€ãt and.sÊdätg:¡

'patient.

l3' While midazolarn can he used üo induce unconsqiciusness, it h¿s no aüalgcsic properiies,

and Ìviüoutpairt reliwinÈ drr¡gs, is not suit¿bleas h form of anæqhçsia as E singlc drug;

14. Midazolam iS not nDe-AÞproved ás thc¡tp/á drugtoprgduce ahôithçSia jlr rnino¡ surgìcal

procdures. Itis never used æ a sqle ;anesthçticth¿t:inlolft$ ariynoliióus Ètirr¡ulj as hlræ

zero ariâlgpsie cff€cr.

15. I h¿ivþ rcviewd the Florida Supreme,Corirr's deciùicrn in .ìtfuhaninad v. gtate,,20tl Fla.

LEXIS 2757' (Dwenb.er 19, 2013). Thir fqctual fìnding made by the eircuit caurt and

upheld by the F'lo¡ida Suprûtne Cour,t sating,that:midazolarn is F'ÐA approved as an

anesthetis iñ r¡inor surgcries is iucsrreet. As stated aboye,.it is not FD.A appnrved as.rhe

so/cdrugforpainfulprooeduresrbes¿useithasnoanalgesiopropertios, J,6,fieves,Rober

I. Fragen, H..ftonald Vinilq David J. Greenblatt ¡ Mídæolam, 'Phurmacologt and,Ilst*s¡ t),

Anesthesiology* 3 I 0,324 (t 9S5).

16.This differs fr.om the barrbiturate pentobarbial, which is approved as asole anestùdio.

Pentobaúital dorls ¡ot have a eeili-ng ef.fect. Pentobæbital produués twc¡ different cffects

orr the brain. lr aots on fhe CABA ¡eeeptor to promote biq{ì¡g, that will in{uce:
UnesrtsoiouSn6Q, br¡t alsO produces sedqtiort diteafly in largo doseç, actìirg as a çAgA
substitritç. lVlidazqlam þinds to a rgcepûor øjawrt tp the,GABd. receptor ar¡d iner-eascs

010
Case 3:14-cv-01149-MMH-JBT Document 14-5 Filed L2lOlJt'4 Page 7 otTO PagelD 426

effective binding of GABA to its rctÊptor ts induce uRconsciousr¡ess, bqt does not ha$e

any direit effect (thc second nreehanism of barbiturates) to produce dsÞp ançstlötio'gtafgs.

Âlso; .onee thai ¡eerytor is satu:rated wlth mtdazôlatrt" adminisEatiO¡t Of ino.te of ths drrrg

dtæs not ido an:¡thíng.o inercaso,the levcl of r¡nsoti$ciousnos-s, Th-e¡e is a mäxÍütrrn cf&êl:

shor,1 of-EEGsïlence (Phyeiolo$f :and Pharmaeo.lggy in A¡cght*io ftaosþc; S¡opltirtg¿n"d

Flillier, 4th edition) which islyhy if is nqt uæd tö inducp corna as Þarbitur¡ts$ atq.

17. IüVîthout an adequatg detennina{jon .Qf tlie dgpth of unçþnseiousnsss" if gilrèrl a paihfb!

stinuli, suojt as 4tr i4ieotiön of vecüloniurn. bromide qr pçtâssîutn. ohtOiltiç., tllèrs iS. a

substantial risk thef Flaintiff'might awaken ftonr the noxious and painñrl sÍirltuli, ltlt/trile a

heavily sedgtcd petie¡t mìght not rospond to name caliing or a,subtlc pinctr, thät is a vory

different level of stimulus than being starved fbr air onoe paratyzed, or having a caustic

charrisal injected inff¿vonously. As.an analogy, a patient asleep migtrt not.å\/akert ib th€

stroke sf a feathsr on thè leg but would oertainly awakøt to a blowtoreh aþplied. to the same

ârea.

l&. T,ts conssiousness ch¿mk desc¡ibod in thc Mid.azola¡¡ Flotosol and, detailed þy tho

,rry:itnesseg in the Happ and Kirnbnougþ øtecutions is uoî sufficienl to deternïne

unèòn.seiousness and inabilþ to feel pain ûorn.ths, noxious stimuli o,f tho vocr¡lioniurn

brornide and poassium ohlorido. Moreovot¡ Defondants: wholly 'failEd to csnduct a

osnsciousnes eheck in fhe most recÊnt €s(Ggution of Eddie Davis.

I 9. Defôndants' t¡seof rnidae. olam ts induce unoonsciou$ress also Ígnores a.substantial risk of

peradoxical reaction's in vulnerable populstiq¡s. into. which Plaintiff, and :arguably the

entire death row popirlation, belonp.

011
Case 3:14-cv-01149-MMH-JBT Document 14-5 Filed tZlOLlL4 Page I of 70 PagelD 427

10. A pariidoxicgl reqctio¡t ÍS whçn thç drug doçs not îvork as i¡ is intsnded. In lhe i'r¡'stant

qtqy aslcop long

seJtjnil, it wguld t[êt¡n that'thc i¡Unatelould not go to sloep and/or not

enough for:thc expçUfio¡l to b-êovoq qnd rnightindUEè..qnxtèty., diS$ordìoarcd nnovwtanq

hyperaotivity arrd/ôr ag$.rassidtt ii¡ liËu öfisedatiitn,

2l . A¡ noted åbove, thcsûipôr.adgx¡a¡-¡ ¡¿¿çtiohs ttmnif:cst in many Y/4yl$rsUsh æ hy.þer'aotiv'iiv

ard.restlossnoss, but árc not.aftcndü by tlrc expectÈd Sed¿tlvq effbqts, atid ers. aÉûe.s¡ed

by reverrsal of ¡nidazotam, not furtbcr administ¡¡tion. Midszolafn dqn þ.revprsçë b,y

administeri n g tlre d rug Roina¿i c<jn (lradc namë F I úinazeni l)'

22, Studies show that when midazolam is given in high dos* to the elderly (over 65), to peoplo'

withahistory ofaggression.ori.mpulsivi.ty, a histol.y ofalcohol ¿6sge,.and otherpsyohiatric

disorders, thero:is,a substânüal risk of a pâradoxical reæti.orr. I havç been advised by

counset that Plaintiff suffers from some dr âll,ofthesoconditions.

23. Flrther compounding the risk of using midazolarh æ thc frtst drug is the hct that a

neuromuseular blocking agcnt; vesuronium brornide¡ is usod ,as the- sccohd dntg iti thc

Mid¿zoÌam Frotocol, Tho vecuroniu,m'bromide would'paral¡ee ,Pleintitr'ànd.,render him

uuabic to cor¡vey any pain or suffering. Plaintiff.would experiçnce a senstltion akin:fo

o-olng þuriø ¿[iye, but not be abie to qonv.Gv the ,feeling of pain or suflosåtion; and the

paiaþsìs would Camõ.ufl4tp any Volqntary movement that might resrlt frorn an incomplete'

lqss of co¡ sc iouÊnes"s'

24. Vesuronium bfor¡ride tnaskq the abili¡y of any Iay observer to discern wl¡ether ths

anesthetio drug has been properly delivmcd. Nfot'èover, ;h'ccausç of the risks associated

with the admlnistr¿tiön gf vccilonuim brgmide and its abilifl to eamouflagpåwarßncssi

even to bained p¡ofessionals, thç Arnetic4¡ Veterihqry Mediqai Assooiation (AU\,ÍA)

012
Case B:14-cv-01149-MMH-JBT Document 14-5 Filed 12l0U14 Page 9 of 70 PagelD 428

prphibitç thc usu of pa¡elytic$ for ôuth{urasia sf animals: By statuþ Flo¡ida also Brohibíts

thç usë of Bar'¿lyt¡os ih uair,ral eutluanasie Fl. Stat .8?8;053(3). The only pur-pose of the

admiilistration of the vecuroniu¡n :brorn,ide'is to ¡n¡iks the exeeution morç aesthetically

plæsing to obsþrvers in that it'reducas.thoobitþ ofiheindividuat being eprcsuted tp movc

or Shsw any pain associaæd wìth the oxccution proeess.

ZS, fh1 third drug in the Midazolanr Proûocol is potassíum ehloride.. Fot'asslum cblsrideis.a

c¿ustiq chemioal and wouldrcaus€ excruciatlngpah to,Plaintiff upon injecito¡.i.flre:,i.$ npt

ptaced into and meintained in a surgical plane of anesihesia from the.¡UidåZolarn tlie
'fÕr

duralion of rhe execution.

26. fn order to appropriatcly deter.mine comsciousness gfter the adr¡linistratiq¡rl qf midazotath

as described in the Midazolanr Pro¡æol, Þefendant$ Would nsed to wait seryþral ûinütes

and then oondue¿ an adequote cgnse¡ouu¡Êst check, whish t.hey are not ti,âinoil tò, do,

C;srrectional persornel rannot bc adeQuatoly trained without the .formel repetitive

'afrgsthgsiq ÊxperiçncEoqe'obtainç ovqr a four yeqr rÈsidency in anssthssia afterra,four

yc.ãrcÕur-s.e. of mediç{i tchçoJ a¡¡d afqu¡;ye¿.r pre+riedical prÈpàrátion.iti collcge.

27. Datennin.Tirg vhgúqr soiheoúe ïs Tru:ly, inse¡sate uikes repctitive,tràinirrgland:experienco,

'becâusé tt¡e signs that someonÞ is riot i¡rcnsaæ can bc veif .srt,btla I¡,a clinical.setting
" you wþuld typio-ally sæ subtle fine: tnofiri movernç¡ts suèh as a rnoving,of.the ilËeior.,hands.

'Ihis. is nÖt spmetliing that a lay person will neco¡sqrily obsenrre or notice.

28. Mqt'eover, in order to make sur6 an individual will be insensate to nox¡ous stimuli, they,

must be in a surgicul þlaue of aircsthesia, ln clinjoal praot¡ûe, a comrntn nty to tost for a.

.$úrgical plane of änesthesia is to applya surgieal elanç (strarp toothed, e.g: å Kctly) on the

arø w.hefe you .&rê going to ¡nake,the ineision. The pai,n/pressuttr cf€s{d.by this elamp.

013
 Page 10 of 70 PagelD 429
case o:14-cv-01149-MMH-JBT Documenr 14-s Filed 12l0u14

cennot be.equated with a hurn4p þciqg so4dVÉtihg a trapt¿ir¡s pindi;tousliirtg.an eyelld,.o.r

shaking a Bersou's, shoulder.

29. Ìlowevgr, ln addition to i¡r,itially asses$ing.t¡rrco¡sejouÈ-Res\ unqonsciO.$Sr¡.gss insqt bs

continualþ mqnitgred tl"iroughquttlre r.emainder of thë'execiltti'ojt lt,is ¡rot pli,igsiblUfot any

qf å-
IaJ Bsrs,o¡ to evqlu4tg whcther $rnþO¡¡g is unp$tst{oud. with.Oqt ihe ass¡6¡dnce

prooqssed tÌE€ ¡non'nor or q Ëaincd medlcal pro&ldional'

30. As qvidanæd"by the eyewitness réports. frorn FloridÈ'ç: rvill¡am Hgp.P eIèôutiÈrt) thçie:was'

movçinent after the conscir¡usnçss checþ which indicates an insuffìsient aile$Thetic <lepth

prior to the a.drninistration of the second snd third' drugs. Thc mÖvelr¡ent of Mr; 'Flapp is

absolute eVidenae of his riot being adoquatdy anè-sthetizöd. 'dn individual docs
not make

Ittovpms6üî if he is totally uD@nsqious arrd ânesthìsti?ad, Tliersfore thh.

potocol failed. It

is my OÞiniorl, tliat tliç. worst Bossiblê dê¿th expóri¿nss. was. dellvEred - the'paralyäc
unable to'draw a
cffectivcty bulying the p8tient alive, whose agony àt beingawårebut
.detivery 'of a eeustic
breath was onfy brought to.a horre¡ldous end through'thc agonizing

chcrnical surging. through-his body.

ûre
31. The eyewifncss rcport fbom Kimbrougþ does uot dæcrfbe such;movornen! howcver¡

affidavit states that view of tL¡e innrate was obstruated by the sheet th¿t was tfited over his

.body. Additionally, in the Kirnbrough execution, the'}Iêndrix exeaution, and the,Ðavis

execution, the imr¡ates' hands were tightly bandaged, whioh wotrld preventtl¡e o-bservation

ofthesubtle firre motor moveñeht$ one would See if a psrsoh iq eithø nÖJ tlnconsçiÓus or

has awakoned dirring the execution. Thcreforç¡ it appears that Þe,feudanfs hs.ve. tb!çn

afÏirmarive sJeps rq minimiee th9 o. þsêrvat¡p.4 çf pgtqntial 'movsmþriÎ aftç¡ the

,administrgtion of the midazolam,

014
Case 3:14-cv-0114$,MMH-¡BT Document 14-5 Filed L2l01,lt4 Page 11 of 70 PagelD 430

32" The.cxeoutíonsof Muharnmad. and Chav,eu, whsrü i"twæ æported tftatMuhamrnadns ey.e

.opened and Chavez' feet rnoved after the:,admlni.stration .of '*tc mida¡olqm, sffprs

a{ditional examples of fine motror moverrrent indisating:eonÞsloûsrrass,artd furrhër sgppg{ts'

my opÌnion that rnìdazolar¡ in any doss'is.un¡ible to rçnder Flaintiff,r,elia.þfy insç¡s¿lo fsr

rhe.adnúnisçation of the çeco¡d a¡.ld ¡n"ird dnrgsi

33.,I hwe rovieu¡ed tþe FDLE lggs from soveral qf Dsfcqda¡b.' midâgçta.m, exgþutlon$. It

app€ars that in flll casqs, the timq bgtween the cp:nclusian 0f thË administ¡eiiott of the

midszolar¡, lte consoiou$nesscheük; alid th€ admigisttaqiOn ofthqveeu-ronium t'ro¡UidÞ is:

one minute or less. This ilno¡nt of timc is insufficient fbr a graded an<l ap¡iroprio'tÉ

congciousnesg eheok añd expo"seÞ Piaintiif to a subsfântjal risk of ssrious harm.

34, As notQd ,abo-ve; whlle tlrqre iô no scientific JiteraRrrÉ that has festeü,the effecus of

midaizolarn attho dosag€ anticÍpatcd by Defendants in úreirþro-üo,col, wé now have amassed

a wgalth of info-rr¡ation;f-oËl pr:èvhus cæeþutiohs involving tnidazoiam.

35. T:hêfð iarrrains no scfçntific lifêrattire tttd n* telted the u.CE cif rnidazqla¡n as a humftre

iùa¡rrlsr to adminiSter lethal iújoclions in hu¡nan¡ orrin an:imal ,eutli,ùnásia. .floweyeri tte

available evidence to.date strongJ,y rsupports' PJainriffs ;contenlion tlmt the, lvfidaaolam

Plotscol 'is inhrr¡nane, sreates a substantial rìsk of seri:or¡s hatn, and arnounts to

cxperimentation on human subjeets and vrilnerable populations, whielr is prohibi:fed by

federallaw.

36,'l'hc Josryh.l#ood sxecutíon provides o-bjcctive, scientifiB evidcnec o.f the unsuitability.of

mid*zolam to guarantee suffioient anesthetic depth to,al'low .Plaintiff to. withstand the

noxior¡s st¡mt¡l¡ of tlæ seosnd and ihi¡d dn¡gç.

xq

015
case 3:14-cv-01149-MMH-JBT Documenr 14-5 Filed LatouL4 page L20t 70 PagerD 431

37..fbe executìon logs, aswell as theeyowitness reports frvhicù,1 arc,atuched tothi'sDpsla¡ation;

,as Exhibit Q reveal that a 750 rng dose o$: midazolam h'insuffrsient to grrarantee that a

.p.r.son wil¡be inspnsateforthcproposd intcrvsntion, in ancxoctttiotl setting..tåoproposod'

jntervention woritd'bo the administration,of thê sæond and thitd.dlugs" Ihis,is?$.0''mg'

more tbanthe doæ presoribod.in Defondûnt$r Midazolam Protoool.

level of pain zufferedrby Joseph ü'oo{'in

3g. Whilo I ¿m nor oi.forìng an opi¡ ion ,tegarding the
is
bis cxeoution us.ing the two-drug pratogol of midazolan and hydrornorpÞone,''ii

undisputed that under Defendantst three-drug pfotocolr ho

would havo ørpcriencÈd

sutrstantial pain. If the 500. mg of midazolam doçs not render Fl¿intisinsonsate, ho will

of the soctlnd and third drugs"

u¡.doubtedly be in excruciati¡g pain upon thÉ:admirtistration

yst,will be unable to expr'e$s lnovement or pairr. beoauçc of the uçq Sftht pstalylie.

3g. fhe only reaso$ Dofendants have not+enductcd exrir¡ofdinpuly'lc.rtgthf c,xeoÛfioils, rsltph

âcts. quiekly to stop

.qs was seen in the Joseph Wood ca$q, is hocause p-gtassium chlslide

the hogti and P-roduÙç üetith.

of Clayon Lockctt in Oklahoma usêd an identisâl drugr oombination 'a¡

40. The èxecutlon

Defendants intend to uss, though Oklahoma's protocol catls fof lOOfng,0f midazolÉnn

insæad of 500mg'
and rnaintain
4l . The intarnal report conduc.tod by Oktahoma identíflted the'ínability ro achieve
prob'lert'as'lwo
v.aou$ aecçss and the faiture to have contingency plans in ttre eveût of a

rnajOi contributÍng factors to thE botchocl execution' Flowever, thc'report eould not

the ability-
determine thc suitability ofmidazolam itsclfi because thc IV failure complicated

to dctenninc the effectivancss of the drugs'

11.

016
Case 3:14-cv-01149-MMH-JBT Document 14-5 FiledLZllLlL4 Page 13 of 70 PagelD 432

42.In sumrnar]; rnidazolâm is an uusqit4ble ehoiæ as the'fiIst drug in a thrpe drug protÔcol

æy doso gUâtadtee à pcfson

for th¡ee :reâsotrs. First, it has a ccililg effoct and eannot:at

auð ln$t t$âto to the,'pæûfu[ sffÊpt$of 6c sccond nrd third dhrgs'

will be rmcousoioue

Seoond, iÈhas,no anaþesiC:prðperliÈq; tktefore çvmif it'doæ produce;uloonsoioUsness

et the S0omg,dosoi ü¡e llitriist¡s sti$ùli of:the,eecond $4 thitd'idrugswillllkoly ovuoorile

roaotlsns ih vulnerâblo
orr.y anesthetia,effcct. Third, ithes'afi mo¡eased risk of parado.ïieal

populatlonq ts whieh Plairrtiff betongs'

provided tlrl¡$fbr' it isny'opiitíon toa

43; As suc}* based on üo informatit¡n tbat l..havc bcen
by
roasonable'dogree o'f uredieal seúåinfy that using rnidæolam in the mannøinre;ndeil

hanq* to Plaintif'f'
Þefind¡næ in tho ù4idazolarn Prorocol,creates a substadtiat nskof serlous

44, If¡were given addition¿l infonnatiol, $rcb aspioures Of iho exag-t sÊt:up' an oxaminatlon

exoeulio¡\
of thè erecrrfion chanrber, a video of thc :practíse n¡rrg, a'vlde0'Of the asfilÞl
dçtailed logs of
spccifioally inptuding close picnrresof all connectisns and tubingi; more

$tÒräge conditions pfdn¡g-ô'

timing:Of delivcry Ofthc actuai Chemicslo, o<pirafioa datæ,and

trainiag and e*pei.icnce of lhe person conüupting oonscisusness ehcc\ I wo¡¡kl bs",ât'le ffi'

offeir a morecomPlote oPiriion.

üS-e. I declueqrrdø;pgnalç of pe¡jury thæ üre bre'gsing is ti'ut

Pursuant to2& Seç. 1746
and co.rÉçt,

D¡
Add¡$q. alç" f.Pàr, trL *ilt3,
E-mail:

Datedthis 1ø,dayof ?¿fo^fu ,2A14.

12

017
 IN THE CIRCUIT COURT OF THË.
sEcoND JUDTCTAL crRcurr, ÏN
AND FOR JEFFERSON COUNTY, FLORIDA

CASE NO. L992-CF-22

STATE OF FLORTDA

vs.

PAUL AUGUSTUS HOWELL,

oefendant.

voLUME rr - Pages L34 thru 199

PROCEEDINGS: EVIDENTIARY HEARING

BEFORE: THE HONORABLE ANGELA C. DEMPSEY

DATE: February LL, 20L4

TIME: Commencing at 1-0:40 a. m

Concluding at t2:L5 p.m

LOCATION: Leon County Courthouse

ral I ahassee, F'lori da

REPORTED BY: rugen'ia B. Lawrence, RPR

Official Court RePorter

eugenia B. Lawrence, RPR

official court Reporter
018
Leon county Courthouse, Room 34L
ral I ahassee , FL 32 301-

019
 136

1- APPEARANCES

2 REPRESENTING THE STATE:

3 CHARMAINE MARY MILLSAPS, ASSISTANT ATTORNEY GENERAL

CAROLYN SNURKOT^/SKI, ASSOCIATE DEPUTY ATTORNEY GENERAL
4 OFFICE OF THE ATTORNEY GENERAL
STATE OF FLORIDA
5 PL-01, THE CAPTTOL
TALLAHASSEE, FLORTDA 32399-1050
6
EDDIE EVANS, ASSISTANT STATE ATTORNEY
7 OFFICE OF THE STATE ATTORNEY
LEON COUNTY COURTHOUSE, SUITE 475
I 301- SOUTH MONROE STREET
TALLAHASSEE, FLORIDA 32301.
9
MITCHELL D. BISHOP, ASSTSTANT ATTORNEY GENERAL
1-0 OFFICE OF THE GENERAL COUNSEL
444 SEABREEZE BOULEVARD, SUrrE 500
1-1_ DAYTONA BEACH, FLORTDA 32LL8

L2 REPRESENTING THE DEFENDANT:

1-3 SONYA RUDENSTINE, ATTORNEY AT LAW

253T NW 41ST STREET, SUITE E
L4 GAINESVILLE, FLORIDA 32606

l-5 MARA V. J. SENN, ATTORNEY AT LAW

ARNOLD & PORTER
r-6 555 TI^IELFTH STREET, NW
IiVASHINGTON, DC 20004-L206
L7

1_8 MTCHAEL TYE, ATTORNEY AT LAW

ARNOLD & PORTER
1-9 555 TWELFTH STREET, NW
IVASHINGTON , DC 2OOO4- L2O6
20
MICHAEL UFFERMAN, ATTORNEY AT LAW
2L MICHAEL UFFERMAN LAI,V FIRM
2022-1 DIEHL ROAD
RRVIIIOND
22 TALLAHASSEE, FLORIDA 32308

23

24

25

020
 L37

1_ ÏNDEX

2
Iì/ITNESSES: PAGE:
3

4 ROSh/ELL LEE EVANS, J R.

5 Direct Examination By Mr. eishop 1,42

Cross Examination By Ms. Senn L49
6 nedirect examination By Mr. eishop L64

7 DAVID LUBARSKY

I ojrect Examination By Ms, Rudenstine L70

cross Examination By Mr. eìshop L72
9

1_0 TIMOTHY HAMILTON CANNON

11_ Djrect examination BY Mr, Evans 175

cross Examination By Mr. Tye t77
t2 Redirect Examination By Mr. Evans 1_9s

13 STATE'S EXHTBIT:

L4 1 L43

1_5

16 certificate of Reporter 1_99

L7

r_8

L9

20

2L

22

23

24

25

021
 138

1_ PROCEEDINGS

2 THE COURT: Okay. So we're back on the paul uowell

3 case around 1-0:30, instead of 9:00 today, because

4 Mr. ufferman sent an email last night around 7:00 or so
5 ìndicat'ing that the defense did not p-lan to call
6 Mr. McDonough as a witness and the next witness wasn't
7 avai I abl e unti I about L0: 30. rs that correct,
8 Mr. ufferman?
9 MR. UFFERMAN: Good mOrn'ing, YOUr HOnOr. YeS, that
1_0 is correct. rhe defense, after consultation, decided not
LL to present the proffered testimony of rt'lr. tvtcoonough.
L2 THE COURT: okay. Rnd then the lawyers via email

1-3 brought up a second jssue regard'ing whether a reporter

L4 I be requ'i red to testi fy j n a moti on to quash rel ated
wi I

1-5 to that. Ms. Millsaps brought up that issue vja email.

1_6 Rnd then Mr. ufferman poìnted out that the defendant only
L7 planned to call the reporter depend it would be

1_8 dependent on what Mr. cannon said today.

19 is to hear from Mr. cannon and then
so the plan
20 address the motion to quash after that. and r did sìgn
2L an order allow'ing the lawyer for the newspaper to appear
22 vi a tel ephone.
23 MS. MTLLSAPS: Your Honor, we may have an even
24 we've sort of moved a step beyond that. what we've
25 agreed js that we are goìng to put Warden Cannon on the
022
 139

l- stand for the sole and very limited purpose of descrìbing

2 the current protocol and the steps of the consciousness
3 check. h/e are not go'ing to djscuss or el jcit f rom him
4 prior executi ons or any
any test'imony regardi ng
5 occurrences durìng those prìor executions.
6 So, with that agreement, what we understand, and

7 r'll let Mr. ufferman speakfor himself, but we

I understand that they are go'ing to withdraw their subpoena
9 with that understanding.
r-0 MR. UFFERMAN: That is correct, Your Honor. As I
1_1 expl ai ned vj aI I ast n'ight, those wi tnesses woul d
emai

T2 only be for the purpose of rebuttal of any observations

1_3 of prior executions and, with the State's representatjon
t4 that Mr. Cannon will not go jnto that area, then
1_5 obviously our witnesses would not be relevant.
1_6 we apprecjate the State's explanatjon as to what
L7 Mr. Cannon will address. Rnd as long as we stick to
1_8 that , the re ' s no poi nt i n ho-l di ng any heari ng . It sounds
1-9 like it would be moot.
20 THE CoURT: Okay. At this poìnt, I guess t'm going

2L to kjnd of just hold off on canceling that 'lawyer

22 appearing by phone just to make sure everything goes
23 smoothl y w.ith Mr. Cannon. It sounds I i ke i t's goì ng to,

24 but we mìght as well just keep them on standby.

25 MR. UFFERMAN: Your Honor, I think the only concern

023
 140

L was that r don't think the State intends to put

2 Mr. Cannon on this mornìng, r thjnk they intend to put

3 him on this afternoon

4 THE COURT: Oh, r didn't know that. who are we

5 hearing f rom thi s morn'ing?

6 MR. BrsHoP: That's probabl y Dr. Evans ca'lf i ng i n
7 right now.

I MS. MILLSAPS: DT. EVANS.

9 THE couRT: okay. nll right. So maybe r'll have

1_0 the newspaper lawyer, r think her name is Ms. Fugate,

1_1 r'll have her on standbyfor thjs afternoon instead.
L2 MR. UFFERMAN: That will work, Your Honor. Thank
1_3 you.

t4 MS. MILLSAPS: Thank You.

L5 THE COURT: okay. Dr. Evans, can you hear me?

16 MR. EVANS: Yes, r can, just barely.

L7 THE COURT: okay. so that speaker -- the phone

1_8 comes out over here? okay. So r guess if everybody

r-9 could just talk loud so Dr. Evans can hear us okay.
20 Anythj ng el se that we need to tal k about before we

2L start with Dr. Evans' testimony?

22 MR. UFFERMAN: No, Your Honor.
23 THE COURT: Anything else from the State before we

24 get started with him?

25 MS. MILLSAPS: NO, YOUr HOnOr.

024
 L4L

1_ THE COURT: Okay. And does he have a notary with

2 hi m?

3 No. We've previously sworn him over

MR. BISHOP:
4 the phone through the clerk here, Your Honor. we've done
5 that i n p rev'i ous heari ngs .
6 THE COURT: Okay. Do you have any objection to
7 that, Mr. Ufferman?
I MS. SENN: NO, YOUr HOnOr.
I MR. UFFERMAN: Ms. Senn will be handlìng this
r_0 witness, Your Honor.

1_ 1_ THE COURT: okay. rhanks.

L2 Rnd y'al 1 probabl y recogn-ize hi s voi ce as wel I .
1_3 MR. BrsHoP: rt js in fact him, Your Honor'
L4 okay. So, Dr. Evans, if you could go
THE COURT:

1_5 ahead and raise your rìght hand, please.

1_6 (wrrruess swoRN)

L7 THE coURT: Okay. Thank you. please state your

1-8 ful I name.

19 THE Iì/ITNESS: My name i s Roswel I tee Evans, J r.

20 THE COURT: OkaY. rhank You.

2L okay. You can 'inqui re.

22 whe reupon ,

23 ROSI^IELL LEE EVANS, J R.

24 was called as a witness, havìng been first duly sworn, was

25 exami ned and testi fì ed as fol I ows:

025
 L42

1_ DIRECT EXAMTNATION

2 BY MR. BISHOP:

3 a rhank you, Your Honor. Good morning' uitch eìshop

4 on behalf of the state of rlorida.
5 Dr. Evans, can You hear me okaY?
6 A Yes, I can.
7 a rhi s i s Mr. aì shop. You 've al ready i ntroduced
8 yourself my name. Can you gìve a brief introduction of what

9 your current posìtion and occupatìon js?

1_0 A Yes. currently, r'm a professor and dean, Auburn
1_ 1_ uni vers'ity Harrj son school of eharmacy.

12 a Rnd professor specifically of what?

1_3 A eharmacy practi ce.
L4 a what is your educational background?
1_5 A I hold a bachelor's of pharmacy, a doctorate of
1_6 pharmacy degree for resìdency, post-graduate residency.

t7 a h/e're go'ing to get to your cv jn just a second, but

1-8 can you gìve a general descrìpt'ion briefly about some of your
1_9 experi ence i n cl i ni cal pharmacy?
20 A Yes. My employment h'istory began with the
2L Universìty of Tennessee, where I Was a professor focus'ing on
22 psych'iatry. I subsequently left and went to the Univers'ity of
23 M'issouri , Kansas C'ity, where I was a member of the School of
24 eharmacy faculty and also the Department of esychìatry.
25 r eventually became department head there, res'idency
026
 t43

1_ d'irector, taught both pharmacy and medical nursìng students.

2 Rnd 1-9 years ago r moved to Auburn as the dean and

3 professor.
4 a Do you have any board certifications?
5 A Yes, r a board-certi fj ed psychi atri c pharmac'ist.
am

6 r'm also a fellow in the Rmerican co1'lege of clinical

7 eharmacy, a fe11ow in the Amerjcan society of Health systems
8 pharmacists. That's probably enough words out.
9 a rair enough. Dr. Evans, r have here marked as
r.0 State's exhjbit B here in the courtroom a 46 page document
1_L revised in October of 201-3 that is your curriculum vjtae. Is
L2 that a correct representation?
L3 A YCS.

L4 a Rnd you've had a chance to review that before you

l-5 submitted it to us?

1_6 A YES.

L7 MR. BISHOP: May I approach, Your Honor?

1-8 THE COURT: YES.

1-9 At this time, I would like to

MR. BISHOP: move

20 state's exhibit B in as state's exhibit 1-.

2L THE COURT: AnY objection, Ms. Senn?

22 MS. SENN: No, YOUr HOnOr.

23 THE coURT: So that will be entered as State's 1-.

24 (stRte's EXHTBTT NO. L RECETVED rN EVIDENCE.)

25

027
 L44

L BY MR. BISHOP:

2 a Besjdes your duties as a dean and professor of

3 pharmacy at Auburn, do you have any other type of consultìng
4 practi ce?

5 A Yes, r do prov'ide some consultation to private

6 jndividuals regarding psych'iatrjc issues. I'm also involved
7 pe riodì cal 1y i n I ega'l consul tati on .

I a Do you testify in criminal proceedings in those

9 I egal consul tat'ions?

1_0 A Yes, r do.

1-1 a For the state and the defense?

L2 A Both.
1_3 a okay. You testi f i ed recentl y j n the ev'ident'iary
L4 hearing of chavez v. palmer in the U.S. oistrict Court in
1_5 Jacksonville on rebruary 5, 20L4; is that correct?
1_6 A Yes, it is.
t7 a You've also had a chance to review Dr. tubarsky's
l_8 affidavit in this proceeding; js that correct?
1-9 A Yes,r did.
20 a r want to start wj th some basj cs. what j s
2L mi dazol am?

22 A ui dazol am i s a benzodi azepi ne hypnot'i c , primari 1y

23 used to of anesthesia.
induce various levels
24 a Have you had a chance to revjew the lethal -injectìon

25 protocol from the Department of Corrections here in florida

028
 L45

1- f rom September 9, 20L3?

2 A Yes,rhave.
3 Q rt calls for 500 mill'igrams of mjdazolam to be
4 admjnistered to the subject jn the initial drug of the three
5 drug protocol; is that accurate?
6 A That's true.
7 e what would be the effect of that dosage of midazolam
I on the i nmate?
9 A Well, that's a toxic dose. It is not a therapeutic
1-0 dose. It would induce a comatose state in an individual with
i-l- al I the sequel ae of that state, 'incl ud'ing di ffi cul ti es wi th
L2 respiration, p€rhaps respìratory arrest. It would simply
1-3 cause a person not to be able to sense his envjronment, is
L4 prìmar-i'ly the kind of effects that the drug will cause at that
l-5 dose.
16 a How long would jt take to render -- how long would
L7 it take for the midazolam to take effect?
j-B A rt begìns to have an effect almost jmmediately, peak
1"9 effects from the drug within ten minutes, and renderìng
20 someone comatose probably much quìcker than that.
2t a At that poìnt, once it's taken effect and rendered
22 the subject comatose, would the subject be able to perceive
23 paì n?
24 A No. ey defìnìt'ion, if you're in a coma, you're not
25 abl e to pe rcei ve pa'i n.

029
 L46

L a Are you familiar with, in your experience, midazolam

2 being fatal in subjects at much lower doses than

3 500 milligrams?
4 A YES.

5 a can you tal k aboutthat a I i ttl e bi t?

6 A rhe reported doses in the literature suggest that as
7 little as a .71 nicrogram per k'ilogram dose, wh'ich is about
I f i ve mi I I 'i g rams , has cau sed death . the re are 81 case repo rts

9 in the United States of midazolam causing death at various

1_0 I evel s of dose.

1-1 a Rnd in your clinical practìce, you do research not

L2 only in the therapeutic use of the drug but also when the drug
1_3 has been abused or been administered at toxic levels?
L4 A YES.

l_5 a tf you were intending to render someone unconscious

L6 and your goal was to render them incapable or unaware of
L7 noxious stimulj or pain, would a dose of 500 milfigrams, in
1_8 your op'inìon, be sufficient to achjeve that result?
1_9 A YES.

20 a Is midazolam usually combined with another drug like

2t an op'iate or something like that?
22 A It certai nly can be, especì a]l y -if you' re deal ì ng
23 with therapeutic anesthesia.
24 a rn a medi cal settì ng?
25 A rn a medi cal setti ng.
030
 T47

1 a why is that?
2 A rt produces a much more level impact, a much more
3 level response to the drug. You can also reduce the dose of
4 both drugs.
5 e Are you fami I i ar wi th paradox-ical reacti ons that
6 could occur with midazolam?
7 A YeS.

8 a can you expl ai n that?

9 A wel I , the mechani sm i s qu'ite unexpl ai nabl e, but i t
1-0 typically happens in inductjon phases of anesthesia in low
1-1- doses that exace rbate unde 11 y-i ng ki nd of pe rsonaf i ty t raj ts
,

L2 anger, rage, those kjnd of thìngs.

1-3 a those reactions are all very observable, are they
L4 not?
1-5 A Yes , they are.
l-6 a what js it, about less than one percent?
t7 A LesS than one percent incjdent ¡k¡! at least in the
1-8 general clinical trials and studjes that have been done with
1-9 the d rug .

20 a rn the circumstances with the lethal ìnjection

2L protocol where the toxic level of 500 mi11ìgrams of midazolam
22 i s admi ni stered to the subj ect, i s j t possi b'le that you s'imp1y
23 sk'ip past the paradoxìca1 reaction point?
24 A r think that's entirely possìble.
25 a rs there a ceilìng effect to mjdazolam? Are you
031
 148

1- fami I i ar wi th that?
2 A rt's been discussed. rt's hypothetjcal. At this
3 dose, ro one rea1ly knows if there is a ceifing effect. But,
4 gìven the toxic effects of this drug, r doubt seriously we're
5 goi ng to see that.
6 a why i s that, ât thi s dosage?
7 A Essentia]ly, we're saturatìng receptors that are
I responsible for the drug's action jn the amounts that r don't
9 thjnk that we are going to see a reversal.
l-0 a rs the effect of midazolam at this dosage, is it
l-1 si mi I ar to barbi turates , such as sodi um th'iopental or
L2 pentobarbi tal ?
13 A well, they're different drugs.
L4 a RbsolutelY.
15 A But the effect i s si mi I ar. They' re not j dentj cal .

L6 a Sure.
L7 A But they're similar'
1-8 MR. BTSH9P: May r have one moment' Your Honor?

1-9 THE COURT: YES .

20 BY MR. BISHOP:

2L a Dr. Evans, just a few more questions.

22 rs it possib'le for the subject who's been
23 administered the toxic dose of midazolam to actually
24 experi ence i nvol untary movement?
25 A well, jt is certainly hypothesized that that can

032
 L49

1- occur. But if indeed there is involuntary movement, it could

2 well be that the drug is not workìng, has not been injected
3 properly. Or it could be involuntary movement secondary to
4 some respìratory gasp that the jndividual may experience as

5 they go into resPìratory arrest.

6 rt's a little unclear.
7 e of the dosage level of
Based on your understandìng

8 thi s drug, woul d any i nvol untary movement or gasp for a'i r,
9 would any pain from that be perceìved by the subject with this
1-0 I evel of mi dazolam?

1-1 A No.

L2 MR. BrsHoP: r have no further questions at this

1-3 ti me , You r Hono r .

L4 THE COURT: Okay. Ms. Senn?

1-5 MS. SENN: Thank you , You r Honor.

16 CROSS-EXAMINATION

L7 BY MS. SENN:

l-8 a Dr. Evans, this is Mara Senn and I am represent'ing

1-9 Mr. Howell. Rnd good morn'ing to everybody.
20 A Good mornìng.
2L a Rnd good morning, Your Honor.
22 So, you testifjed that you have testified before in
23 I ethal 'i n j ect-i on cases . rs that co r rect?
24 A Yes.
25 a Rnd how many have you done?
033
 150

1_ A r thi s i s the thi rd one.

bel i eve

2 a uaybe the fourth? pardo, Mohammed, and chavez, and

3 now this is the fourth?

4 A Yes. You're correct.
5 a Great. rhank you.
6 Rnd how many of these cases were for the State?
7 A All were for the state.
8 a what did you review today or what did you review in
I preparation for your testjmony today?
1_0 A what r revi ewed was the proceedi ngs from the chavez
1_1 case and the supplements prov'ided by your office to the State.
L2 a okay. You are not a medical doctor, are you?

1_3 A No, I am not.

L4 a Rnd you've never personally induced anesthesia in a

15 patj ent?
16 A NO.

L7 a Rnd you've never personally used midazolam on a

1_8 patjent therapeutìca11y, have You?

1_9 A NO.

20 a Rnd you've never personally used vecuronium bromide

2L on a pati ent, have you?
22 A NO.

23 a Rnd you cannot, of, your own, evaluate a patient and

24 prescribe medication, can you?

25 A trtot wi thout bei ng i n a col I aborati ve arrangement.

034
 151

1_ a Meaning not unless a doctor allows you to do that?

2 n nìght. Exactly.
3 Q Rnd you've never personally done an evaluation of
4 the consciousness of a patient, have you?
5 A No. rf r di d, i t was some ti me ago when r was
6 practìcing internal medicine.
7 a But that woul d have been a whi I e â9o, rì ght?
I A Yes.
I a Now, you would never use midazolam alone as a
1-0 anesthetjc in a major surgery, would you?
1-1- A No . That ' s not common p racti ce .

L2 a Rnd the other drugs so other drugs would always

1-3 be used in a major surgery with midazo'lam, is that correct?
L4 A That's true.
15 a Rnd that's basically to make sure that pain does not
l-6 di stu rb the pati ent , co r rect?
L7 A Wel I , qu'ite f rank'ly, i t's to generate a much more
18 even anesthesi a.
1-9 a so i t has nothi ng to do wi th paì n?
20 A No.
2L a So the fact that you would paìr mjdazolam with an
ZZ opjoi d that has pa'in suppressi ng qual j ti es , that has nothì ng
23 to do with itZ
24 A At a therapeutìc 1eve1, I think you would want at
ZS therapeutic use of midazolam, you would want something else to
035
 L52

l- deal wi th pa'i n.
2 tf we' re tal ki ng about ì nduc'ing a comatose state
3 with this drug, that's not necessary.
4 a Okay. But, in typical practice, you would never use
5 midazolam alone because it doesn't have any paìn-ref ieving
6 properti es, correct?
7 A Not jn theraPeutìc doses, ho.
I a Rnd it doesn't have any analgesic or pain-ref ievìng
9 propertìes at any level, does it?
1_0 A Well, in actualjty, there is evidence that would
1-1- suggest that midazolam has been effectively used for jts
LZ analgesic properties in lower back paìn.
1-3 But when we start talk'ing about general surg'ica1
L4 procedures, this drug would not be my choice to use by jtself.
1-5 a Now, jn the Chavez testimony you remember that
1-6 you testi fi ed, correct?
L7 A Yes.
18 a You testi fi ed i n that case that mi dazol am has
1-9 absolutely no paìn-relievìng properties. Are you changing
20 your testimonY?
2L A wel I , Yês, because r di d have a chance to do a
22 I i ttl e more di gg'i ng.
23 a r'm sorry. r couldn't understand You, sir.
24 A r had a chance to do a little more diggìng jnto some
25 of the I i terature regardi ng thi s.
036
 153

L so, r mean, ì t's not obvi ous'ly, i t's not a major

2 analgesic drug.
3 Q so you found one sudden study that sai d maybe
4 sometimes your back paìn will be relieved?
5 A Yes.
6 a Now, it's ìmportant to ensure that you have pure
7 unadulterated midazolam admjnistering it in any setting, js
I that correct?
9 A Yes.
1-0 a Rnd it is 'important that the drugs are not exp'i red,
1-1- is that correct?
LZ A Yes.
L3 a Rnd it is 'important they are mixed and prepared by
L4 someone who is trained, correct?
1-5 A Yes.
L6 a Rnd do you know how Florida gets its midazolam for
t7 executi ons?
l-8 A No.
1-9 a Rnd do you know who prepares the midazolam
20 i n j ect'i ons fo r executi ons?
2L A only per protocol. r've read the protocol.
22 a You've read the Protocol?
23 A nìght.
24 a Rnd does the protocol explain how the ìnjections are
25 prepared?
037
 L54

L MR. BISHOP: Your Honor, the protocol is jn

2 evidence. rhe protocol speaks for jtself. To have the
3 witness now kind of parrot that part of it is cumulative
4 and improper.
5 Ms. SENN: ln/e11, Your Honor, r think jt's fair game

6 for Mr. Howell to determine what Dr. Evans' opinion of

7 the protocol is.
I THE COURT: rrm going to overrule the objection'

9 MS. SENN: thank You.

1_0 BY MS. SENN:

1-1 a So do you remember how the protocol requ'i res the

L2 preparation of the injectìon?
1_3 A Generally, Y€s.

L4 a Rnd what's Your recollection?

l_5 A My recollection is that jndividuals assìgned by the
L6 warden actually reconstitute the drug.
L7 a Reconsti tute the drug?
L8 A YES.

19 a Rnd do
20 A well, not reconstitute, but pull up the drug.
2L a And do you recall whether those people are requìred
22 to have any trainìng?
23 A f think, from what r reca]1, there is an in-service
24 trai ni ng.

25 a There's an in-service. rn your opinion, is that

038
 155

1 suffi cj ent trai ni ng?

2 L For most scenarios in the medical settìng, I would
3 say 'it depends on what thejr background was, what the
4 intensifjcation of the training was, and how technical the
5 procedure was.
6 a so, ìf they had no medical train'ing, that would be
7 something you would consider, js that correct?
8 A Yes. rn an rV environment for clinical uses, jt
9 would take more than an in-servjce. In this case, when we're
10 inducing a toxic effect and we get the right proportions of
1l- the drug jnto the syringe, it's not too complicated.
LZ a So, I'm sorry, what was the distinction you were
i-3 mak'i ng between the ì n j ecti on and rv si tuati on? rsn 't th j s an
t4 rv situation?
1_5 A It is. But it's for the purposes of generating a
1-6 toxi c ef fect , not a the rapeutì c one .

L7 a so, in other words

j-8 A In other words, we' re not necessaril y too terribl y
1-9 worrjed about thìngs like is this a sterjle procedure.
20 a nìght. So, in other words, jt doesn't really matter
21, if you follow medical protocol, You can do whatever you want?
22 A As long as you are generating the r.ight amount of
23 drug and follow'ing as near perfect as you can to a sterile
24 procedure.
25 a But, basi ca1-ly, you' re say'ing that the standard i s
039
 156

1- sìgnificant'ly lower in an execution context than it would in a

2 therapeutìc context?
3 ¡ Yes.

4 a Now, in order to be on a surgical plane of

5 unconscjousness, you would agree that you need to be
6 unconscj ous, 'insensate, and 'immobi 1e, i s that correct?

7 A well, the term I think r have used is "comatose."

I a Comatose?

9 A Not "surgìcal plane" because "surg'ical plane"

1-0 'implies someth'ing quite different in this case.

1-L a what's the difference between "comatose"

L2 A rhe difference is in a surgìca1 plane we're
1-3 achiev'ing a minimum amount of anesthesia jn order to do an
t4 invasive procedure. In this case, we're ìnducing a rather
15 profound coma, which should result in the person not
l-6 expe ri encì ng any sensat'i on , pai n i ncl uded .

L7 a So let me just rephrase my question then. You would

18 agree that, jn order to be comatose, you would agree that you
1-9 need to be unconscious, insensate, and immobjle, correct?
20 A Yes.
2L a You would agree that general anesthesja is a
22 drug-induced loss of consciousness during whjch the patient is
23 not arousable even to paìnfu1 st'imufi, is that correct?
24 A Yes. uopeful 1y.
25 a so, in a consciousness test, ìt's necessary to
040
 L57

1 measure the depth of unconsciousness, that the depth of

2 unconscjousness js sufficient for the subsequent procedure not
3 to arouse the person who is unconscjous, js that correct?
4 A YES.

5 a Rnd the stronger the noxjous stìmulus, the more

6 f ikely a patient is to wake uP, js that correct?

7 A Yes. rf there isn't a true coma induced, r'ight.
8 A so, ìf you hit someone with a penc'il versus a
9 sledgehammer, you would obviously have a very different
1_0 reaction, is that correct?
1_ 1_ A not. Aga'in , I th j nk what we' re tal ki ng about
uaybe
L2 we're kind of pick'ing at straws here. surgical plane
1_3 doesn't necessarì1y take the person to the same level of coma
L4 that we're talk'ing about with thjs kind of drug-induced coma
1_5 i n thi s exerci se.
L6 a sure. But you would agree that a sledgehammer js a

L7 much h'igher I evel of noxi ous sti mul i --

r_8 A Oh , certai nl Y. Certai nl Y.
1_9 a okay. A person could appear to be under general
20 anesthesia, but unless there was a test that showed they were
2L unconscious enough not to feel a noxious stìmu1us, they could
22 actually feel pain, js that correct?
23 A That's possì bl e.

24 a Rnd if there's enough pa'in, a person mìght become

25 closer to consciousness or actually become conscious because

041
 158

L of the sensation of pain, js that correct?

2 A That's true.
3 e So, testing for consciousness should jnclude graded
4 stimulj, is that correct?
5 n Yes.
6 a nnd what is your understanding of what happens in
7 the rlorida consciousness test?
I A lt's my understanding that the warden does exercjse
9 a graded evaluation.
l-0 a rn what
l-1 A rn response to Paì n .

LZ a rn what way; do You know?

1-3 A Well, 'it's not expljcit in the protocol , so I really
L4 can't be sure. But what I understand, what I've been told is
15 it starts with touch'ing the eye to the poìnt where you either
1-6 begì n to i nduce pa'in wi th grabbi ng muscl e groups and/or the
L7 eye orbi t, whi ch generates a I ot of pa'in '
1-g a s-i r, r'm sorry. I had a ljttle bjt of diffìculty
1-9 unde rstandì ng you.

20 A sure.
2L a It seems lìke maybe you're close to the phone. Do
22 you mi nd repeati ng that? r apol ogi ze.
23 A I said that from what I understand, what I've been
24 told, because it's not clear in the protocol exactly the steps
25 that are taken, is that it starts with perhaps a touchìng of
042
 159

1_ the €yê, the eyelid, and progresses to something as pa'infu1 as

2 pressjng on the occipital orbit, the eye orbit, or the

3 trapezìus muscle, which is in the shoulder.
4 a Rnd so is 'it your understanding that that person
5 pushes it very hard?
6 A YCS.

7 a Rnd would that be as much paìn as a strong, strong

8 pi nch?

9 A tf you ng, for -instance, the occi p'ital , the

start usì

1_0 eye orb'it, i t can be much more pa'infu1 than a pì nch.

11_ a But, in reading the protocol, You can't tell any of
t2 that, can you?
1-3 A No, r can't tel I that.
L4 a Rnd so under the protocol the warden is not rea11y
1-5 required to do anything, he can just do whatever it is he
1-6 personally thinks would be appropriate, correct?
L7 Awell, r'1t not sure about that. one has to assume
1_8 that the protocol would indicate that enough pain would be
1_9 generated. So I'm not I have not witnessed it. I have not
20 read anythi ng speci fi ca1 y about i t.
1

2L a Rnd it's not required by the protocol' correct?

22 A wel l , r don't rìo, the warden the protoco-l does
23 require the warden to assess it. But it doesn't say how.
24 a It doesn't say how. It doesn't talk about level of
25 pai n?

043
 160

L A No.
2 Q Rnd jn the 20L3 protocol, consciousness is only
3 evaluated once, correct?
4 A Yes.
5 Q But in a surgery, consciousness is perpetually
6 monjtored, correct?
7 A Yes, because it is a prolonged event. This is not.
I a night. But one of the reasons that you monitor in a
9 surgery is because a patient could come out of the surg'ical
1-0 plane, i s that correct?
1-L A nbsol ute1y.
L2 a Now, you have testified repeatedly that a high level
1-3 of midazolam will cause a coma, is that correct?
L4 A YES.

1-5 a Are you aware of literature that says it js

16 impossible for mjdazolam to reach a level of flatline EEG?
L7 A r have heard that testimony, Y€s.
L8 a But you d'isagree with it?
1_9 A I think jt is very djfficult to support that, given
20 the fact that the reference that was used for that i s from an
2L intramuscular ìnjectìon at a therapeutic dose, not at a toxic
22 dose.
23 a So have you found any literature out there that, in
24 fact, shows that a coma can be induced by mjdazolam?
25 A Yes. r mean, it is if you were to pull up the
044
 161

L FDA warnjngs and all of the information about mìdazolam, you

2 can induce a coma, respiratory arrest, and cardiac arrest wjth

3 thi s drug.
4 a ìf you're in a coma, you can't move, right?
Rnd

5 n
well, typically not, no.
6 And, in fact, as you agreed wjth me earlier, you
a
7 sajd that if you're comatose, one of the very definitjons of
8 comatose means you are ìmmobìle, meaning you do not move,'is
9 that correct?
1-0 Aght. Exactl y.
nì

1-1 Now, let's move on to vecuronium bromide' r'm

a
LZ sorry, vecuronium chloride. or is jt bromide? r think you
1-3 know what r'm ta'lki ng about.
L4 A nìght
1-5 a So, vecuronium bromide paral yzes a patient, correct?
l-6 A Yes.

L7 a and 'if you were conscious, the paralyzing effect of

l-8 Vecuronium would cause Severe air hunger, is that correct?
1-9 A rf you' re consci ous , yes .

20 a so, it would feel ljke you need to breathe, but you

2L real 1 y can't do i t?
22 A nìght.
23 a sothat's a pretty pa'infu1 sensat'ion, correct?
24 A Our assumption is that it is, yes.
25 a Now, would you agree that vecuronium bromide is also

045
 L62

1 known as a neuromuscular block'ing agent?

2 A Yes.

3 a Are you famjliar with rlorida statute 828.058(3)?

4 A r don't know what that i s because
5 MR. BTSHOP: Objection.

6 THE couRT: Sustai ned.

7 MR. BISHOP: You just shouted off a statute number
8

9 I've al ready sustaj ned the objecti on.

THE cOURT:

L0 You don't need to say anything else, Mr. eishop.

L1 BY MS. SENN:

L2 a Let me rephrase. Are you familiar with the statute

13 that prevents jn rlorida that prevents the use of a
L4 neuromuscular b'locking agent jn the euthanasia of dogs and
L5 cats?
1_6 MR. BISHoP: objection. Relevance.

L7 THE COURT: Sustained. You don't need to answer.

1_8 I'Ve not read the Statute, hO.

THE I^/ITNESS:

19 THE COURT: Dr. Evans, I don't know if you can hear

20 me that well. when r sustain the object'ion, you don't

2L need to answer.
22 THE WITNESS: Thank you. I couldn't hear You, Your
23 Honor.

24 THE COURT: Okay.

25

046
 163

1- BY MS. SENN:

2 Q Do you think vecuronium is necessary in order to

3 kill the inmate in this Protocol?
4 MR. BISHOP: objection. Relevance.

5 THE COURT: Sustai ned.

6 BY MS. SENN:

7 a If a patient were conscious and was adminjstered

I potass'i um chl ori de, they woul d experi ence searing pai n, 'is
9 that correct?
l-0 A rf they were conscious?
1_1- a Yes.
L2 A Yes.
j-3 a Now, you talked about 81- incjdents of death reìatìng
L4 to therapeutic levels of midazolam; is that correct?
15 A We11, I didn't say they were therapeut'ic levels of
1-6 midazolam. I just said there had been 81 deaths reported.
L7 a okay. EightY-one deaths.
l_8 Now, you' re fami I j ar wj th the t-O50 test, i s that

1-9 co r rect?
20 A Yes.
2t a Rnd you're familiar with the fact that at very, very
22 high doses, much hìgher doses than are in this protocol , on'ly
23 50 percent of the tested animals died, is that correct?
24 A That's the definjtion of 1D50, Y€s.
25 MS. SENN: No further quest-ions' Your Honor.

047
 L64

1- THE COURT: okay. Redi rect?

2 REDTRECT EXAMINATION

3 BY MR. BISHOP:

4 a Dr. Evans, what woul d be the depth of

5 unconsciousness at 500 mjllìgrams of midazolam?

6 A rhey would be profoundly comatose.

7 a unconscious and insensate at thjs level?
8 A Yes, by defi ni ti on.
9 a can you say that to a reasonable degree of
10 pharmacol og'ica1 certaj ntY?
1_1 A YCS.

L2 a Rfter the effect at that comatose

mjdazolam takes
1_3 level, would the subject feel the effects of the vecuronium
L4 bromide and the potassium chloride?
1_5 A NO.

l_6 MR. BTSHOP: No fu rther quest'ions , Your Honor.

L7 THE COURT: Okay. Does he need to remai n avai I abl e
1_8 at all?
1_9 MR. BISHOP: No, Your Honor, not from us.
20 THE COURT: How about from the defendant's
2L pe rspectj ve?
22 MS. SENN: NO, YOUr HOnOr.
23 THE COURT: Thank You, Dr. Evans.
24 THE WITNESS: thank You.
25 THE COURT: OkaY. BYe-bye.

048
 165

1 in ten minutes would it

MS. SENN: Your Honor, be

2 poss'ible for Dr. t-ubarsky to gìve a rebuttal?

3 THE coURT: So the State's next witness is

4 Dr. oershwitz?
5 MS. MILLSAPS: No, Your Honor. tde're going to
6 present warden cannon.
7 THE COURT: That's right.
I MS. MTLLSAPS: Dr. Dershwitz isn't available. He's

9 do'ing cl i n j cal rounds .

1-0 THE couRT: He's the one that we're hearing from at
LL 5 :00?

T2 MS. MILLSAPS: YES.

1_3 THE COURT: So when is Mr. Cannon available?
1,4 MS. MILLSAPS: 1: 30.
1_5 THE COURT: All right. Does the State have any
L6 objection to Dr. Lubarsky go'ing out of order for a

L7 rebuttal ?

1_8 MR. BISHOP: Not out of order, ho, Your Honor.

19 THE couRT: Do you have some other objection?

20 I do have one question I just wanted
MS. MILLSAPS:
2L to ask. Are we go'ing to put Dr. tubarsky aga'in, second
22 rebuttal to Dr. oershwitz?
23 THE COURT: Yes, I mean, I'lll not going to let hjm

24 testi fy twj ce. r assume you guys mean he's go'i ng to

25 testi fy now and be done.

049
 166

1_ well, Your Honor, if you would permit

MS. SENN:
2 Dr. tubarsky to testify in rebuttal after Dr. Dershwìtz,
3 we would wait until then. tnte're just concerned that
4 there may not be tjme and we want to make sure that we
5 have an opportunity. tlle prefer to do it after Dr.
6 De rshwi tz .

7 MR. BISHOP: If I may, Your Honor. tf we just have

8 a disagreement between one expert and the other, r don't

9 know that that's necessarily proper for rebuttal unless
1_0 there's something new that's come out that Dr. tubarsky
1_ 1- didn't get to address in his testimony.
L2 r believe everything we've covered. Now, r think we
1_3 have d'isagreement perhaps between the two experts, but r
L4 think everythjng we've covered has been the same subject
1_5 matter that Dr. tubarsky has covered and nothing new has
1-6 arisen during the testimony of or. Evans. t,rle don't
L7 anti c'ipate anythi ng new ari s'ing durì ng our presentati on

1_8 of or. oershwitz.

l_9 MS. SENN: Your Honor, if r may respond.

20 THE COURT: OkaY.

2L MS. sENN: A coupl e of thì ngs. Fi rst of al I , there

22 was new informatjon. There was a new study and a number
23 of new additional information that Dr. Evans introduced.
24 In addjtion, the purpose of rebuttal is to allow an
25 opposi ng wj tness to respond to what thi s wi tness had.

050
 L67

L rhis wjtness had the benefit of hearing about

2 Dr. Lubarsky's testimony and, obvjously, Dr. lubarsky djd

3 not have the sjmilar advantage. So that's another reason
4 for rebuttal.
5 THE COURT: A1 1 ri ght. obvi ous'ly, r mean , these

6 same wìtnesses, everybody has heard from them a number of

7 times over the past couple of months, rìght?
I MR. BTSHOP: Right.

9 MS. SENN: But, Your Honor, as you recal'l , the State

1_0 vehemently objectedto enterìng any of those documents
1"1 into evidence. So that's another reason that we need to
L2

1_3 THE COURT: Vrrhat dOCUmentS?

L4 MS. SENN: OfPrior testjmony.

l-5 THE couRT: Al I ri ght. r don't know what you're

l_6 talkìng about. I mean, Y'âll can use the documents for
L7 impeachment is what they would normally be avajlable for

1_8 and they are available for that.

1_9 Ms. SENN: Right. what r thought you meant' Your

20 Honor, was that the Court would be relying on prevìous

2L testimony from the same

22 THE COURT: NO,that'S nOt What I meant. I meant

23 there's r don't think there's many surprises for any
24 of the 1awyers here during this hearing.
25 MS. SENN: I mean, there was new evidence.

051
 168

1_ THE COURT: okay. what do you want to sâY, Mr.

2 ei shop?

3 MR. BISHOP: Thelast th'ing I was goìng to sâY, Your

4 Honor, in regards to them sayìng that Dr. Evans had
5 Dr. Lubarsky's testimony from this proceeding available,
6 that's not accurate. They had Dr. lubarsky's affidavjt'
7 but he had the transcrìpt from the
same proceedìngs

I chavez proceed'ing that both sides have had access to. So

9 Dr. t-ubarsky had access to Dr. Evans' testimony from that
1-0 proceedìng, which is substant'ially the same as it was
1_ 1- today.
L2 THE COURT: OkaY.

l_3 MS. SENN: RNd

L4 r don't need to hear anything else. So

THE COURT:

1_5 if you want to call Dr. t-ubarsky now just to address that
1_6 new study and anythi ng rel ated to what you know Dr.
L7 Dershwitz is go'ing to sâY, r'll al'low you to call him
18 brìef1y now.

1_9 r'm not go'ing to allow you to call him tonìght after
20 Dr. Dershwitz is done because I assume that's going to be

2L 7230 or 8:00 ton'ight and I have to have an order done by

22 2:00 tomorrow.
23 r'll let you call him brìefly now and he can address

24 that new study that Dr. Evans testi fi ed to. Rnd i f you
25 feel I i ke you need to get i n some evi dence rel ated to
052
 169

1_ what Dr. Dershwitz is going to sây, because r believe you

2 know what he's goì ng to say r mean, ì f he says
3 something total'ly dìfferent tonjght, r will reconsider
4 that. But if he says pretty much what you guys think
5 he's going to and what he's been saying in these other
6 hearings, r'm not going to let you recall Nr. lubarsky
7 aga'i n toni ght.
I MS. SENN: Thank You, Your Honor.
9 THE coURT: So i f y'a'l I want to cal I hi m now.
1_0 in other words, we'll have an
MS. SENN: So,
LL opportunity to move to have Dr. t-ubarsky rebut after Dr.

L2 De rshwitz?
L3 THE COURT:If something tota'lly unexpected comes
L4 up, r'll consider that request if you want to make it.
15 and then, as r mentioned, you can have him do some
1_6 testj mony now i f you I i ke. Do you want to do that?
L7 MS. SENN: Yes. Can we have like a five or ten
1_8 mi nute break?
1_9 THE couRT: Yes. Let me see what time it is.
20 okay. Let' s be back at 1'L: 25.

21, MS. SENN: Thank You, Your Honor.

22 (necess)

23 THE coURT: okay. so do y'al1 want to call

24 Dr. lubarsky?
25 MS. RUDENSTINE: Yes, Your Honor.

053
 L70

1 THE couRT: And yourre going to do the examination,

2 Ms. Rudensti ne?
3 MS. RUDENSTINE: Yes. fhank You.
4 THE couRT: come up , Dr. t-ubarsky.

5 You're here on a second day, so r'm go'ing to 90

6 ahead and place you under oath agaìn, if you could raise
7 your rìght hand.

I (wrrruess swoRN)

I THE COURT: Please have a seat and remind us of your

1_0 ful I name.

1_ 1_ THE WITNESS: oavid tubarskY.

L2 THE COURT: OkaY. thank You.
1-3 Ms. Rudensti ne.
L4 MS. RUDENSTINE: fhank You, Your Honor'
1-5 tdhereupoh,

1_6 DAVID LUBARSKY

L7 was called as a witness, havìng been first duly sworn, was

1_8 examined and testified as follows:

19 DIRECT EXAMINATION

20 BY MS. RUDENSTÏNE:

2L a Dr. lubarsky, Dl. Evans testjfied that sometjmes

22 midazolam has been used for analgesìc purposes for lower back
23 pain. Are you aware of that use and, if so, is that correct?
24 A that is correct, but it doesn't have analgesìc
25 propert j es per se. The rel i ef of pa'in associ ated wi th back

054
 L7L

1 pain that's treated wjth midazolam is due to a change in

2 muscle tension mediated at the CNS level, the central nervous
3 system level . rt's not a di rect analges'ic.
4 a thank you. when you use midazolam in a surgical
5 settì ng and pai r i t wi th an anal gesì c, what's the pri mary
6 purpose for the pairing?
7 A rhe prìmary purpose for the pairing is because
I midazolam js not considered to be approprjate as a sole
g anesthetjc because it doesn't have analgesic properties and a
l-0 pati ent undergoì ng a surgi ca1 procedure m'ight wake up or
LL certainly his body would exhjbit a tremendous amount of stress
L2 related to the noxious stimuli.
1-3 a Is it pretty sjmple to mix and prepare drugs at the
L4 correct dilution?
1-5 A No. That's one of the most common errors in the
1-6 anesthesia field per se. tlrre go to great lengths to both not
L7 only teach peop'le how to do jt correctly, but how to go about
l-8 triple checkìng themselves, et cetera, so that they don't.
1-9 And, yêt, drug dilution mjstakes remain one of the most
20 frequent errors in the anesthesia field.
2L a So, in your field, the anesthesiologìst is the one
22 who prepares the drugs?
23 A Routinely, Y€s, unless there is sometimes a

24 pharmacist in that will mix up and dilute

some departments

ZS drugs in very careful-ly controlled situations in order to try

055
 L72

1- and reduce further the risk of drug dilution errors, which r

2 mentioned are quìte common.

3 Q So you would not have someone other than a

4 pharmacìst or an anesthesiologist preparìng drugs?
5 n No, that would be considered outside the realm of
6 good practj ce.
7 MS. RUDENSTTNE: rhank you.
8 THE couRT: okay. cross?
9 MR. BISHoP: very brìefly, Your Honor.

1-O CROSS- EXAMINATION

1-1- BY MR. BISHOP:

L2 a Dr. Lubarsky, Dr. Evans was not incorrect that there

1-3 was, in fact, a study where midazolam had the effect of
L4 rel.ieving jn pain in the lower back?
1-5 A Yes, it does work by reducìng muscular tension.
l-6 a But it just doesn't have the propertjes inherent
L7 that would nornrally do that?
1-8 A rt doesn't have the abilìty to block noxious
i-g stimuli. what it did was it actually addressed the root cause
20 of the pa'in, which was enhanced muscle tension in the lower
2L back. Rnd benzodiazepìnes and other muscle relaxants are
22 routinely used in that regard.
23 a You said that you actually mìx up your own drugs for
24 surgery?
25 A Yes, draw them up from the vials.

056
 L73

1 a You don't have a pharmacìst jnvolved at all?

Z A we have a pharmac'ist involved when we're for some
3 drugs that are infusions, we wjll have the pharmacìst make
4 them up. But, for most drugs and most preparations in the
5 operating room, the anesthesiologist or the resjdent and/or
6 CRNA, the anesthesi a team, w'i1-l prepare the drugs.
7 a But a lot of anesthesìologists may actually work
I very hand-in-hand, collaborat'ive1y, with a pharmacìst and have
9 the pharmacist draw the drugs uP, correct?
1-0 A rhey woul dn't be worki ng hand- j n-hand. rhe
i-i- pharmacì st woul d probabl y be off -s j te somewhere and provi d'ing
LZ the drugs at the correct dilution.
1-3 a certai nl y. r di dn't mean by hand- j n-hand
L4 side-by-side, but collaboratjvely?
1-5 A Yes , of cou rse .

1-6 a okay. Rnd, again, everything that you do with these

L7 drugs is in a therapeutìc setting for anesthesiology in a
1-8 med j cal surgery, correct?
1-9 A rhat is correct.
ZO a you don't administer these things at toxic levels?
2L A rdonot.
22 MR. BTSHOP: That'S all r have' YOUr Honor.

23 THE couRT: AnY redj rect?

24 Ms. RUDENSTTNE: No, Your Honor.

25 THE couRT: Thanks, Dr. tubarskY.

057
 L74

1 okay. So the State's next witness is available at

2 1-: 30 then?
3 Actually, we've got him here. I was
MR. EVANS:

4 antjc'ipating thjs stuff takìng much longer, but r do have

5 hjm upstairs. so ìf you want to wedge him in before
6 noon, w€ can do that.
7 r don't anti c'ipate hi m taki ng very l ong .
I THE COURT: Okay. I mean, I'll leave it up to you'

9 r'm happy to do it now or wajt.

L0 MS. RUDENSTTNE: we have no objection.
1_ 1- THE COURT: OkaY.

L7 MR. EVANS: r'll step outside.

1_3 THE COURT: Okay. Mr. Cannon, ìf you can come up
L4 near thjs black chair to be placed under oath.
1_5 (wrrrurss st^toRN)

1_6 Okay. Please have a seat and, once

THE COURT:

L7 you're comfortably seated, if you could tell us your full

1_8 name and spe1l your last name.

1_9 THE I^IITNESS: Ti mothy Hami I ton Cannon, C-A-N-N-o-N.

20 THE COURT: OkaY. Thank You.

2L Mr. Evans.

22 trrthe reupon ,

23 TIMOTHY HAMILTON CANNON

24 was called as a witness, having been first duly sworn, was

25 exami ned and testi fi ed as fol I ows:

058
 L75

1- DIRECT EXAMINATION

2 BY MR. EVANS:

3 a what i s your Profess'ion, si r?

4 A r'm the Deputy Secretary with the Florida oepartment

5 of corrections.
6 a Rnd do you have certain duties and responsibjljties
7 during an execution?
I A Yes, sir. For the past seven years almost, I've
9 been charged with being the team leader that is over our
10 execution process here in rlorida.
1_ 1- a rn that capac'ity, are you fami I iar with the current
L2 consciousness test to be used during this execution?

1_3 A Yes, si r.
L4 a Rnd have you prevìously used this test before?
1_5 A Yes, sj r.
1_6 a Rnd when do you administer the consciousness test?
L7 A rhe consciousness test fjrst of all, when the

1_8 execution starts, the first three syrìnges are administered,

1_9 whi ch i s two syr-inges of mi dazol am and then a syri nge of

20 flush, wh'ich is just a flush to get that on into the body.

2L At the conclusion of that first of all, r'm
22 wearìng a radio. Rnd at the conclusion of those three
23 syringes, the assistant team Ieader wjII calI me on that
24 radio. He's pos'itioned in the back with the executjoners. He

25 wj I I cal I me on that radi o and s'i mp1 y say , syri nge th ree

059
 L76

1_ compl ete, Phase one comPl ete.

2 At that time, t will ask hjm to stand by and r will
3 physically then r'm standìng next to the gurney, next to
4 the condemned. r will physical'ly approach the condemned and
5 reach over and do an eye flick of the inmate's eyelashes to
6 see jf there's any kind of reaction to that stimuli. Rnd then
7 r wjll proceed to leaning over the inmate and physically
8 grabb'ing him on each shoulder and shaking vigorously and
I shoutìng rnmate So-and-so, rnmate So-and-so.
10 of that shake-and-shout, I will then
And, as part
1L reach and grab the trapezoìd (sic) muscle and squeeze that
L2 firmly to see if there's any reaction to that pìnch.
1_3 a nnd each of those processes you just described, the
L4 physi ca1 processes of the eye fl i ck and the shake and the

l-5 pinch, do you do it with such a degree as to get a response?

1_6 A Yes, si r.
L7 a Rnd once that once you've completed that, if
1_8 there are no responses, what do you next do?

1-9 A Once r that, if there's no response, then I

complete
20 will key my mike and say into the radio to the assistant team
2L leader that the inmate appears to be unconscjous.
22 At that time, the medical professionals who are jn
23 the back with the assjstant team leader, they have observed me
24 do'ing those checks and looked for any reaction from the
25 i nmate. They' re actual 1 y 1 ookì ng at the j nmate's face on a

060
 t77

1- screen. They've ggt a camera trained on the inmate's face.

2 they're look'ing at that monitor and looking at their EKG
3 monitors as well. Rnd if , after look'ing at all that and me
4 administering those physical tests, they agree that the jnmate
5 i s i ndeed unconsci ous, then they wi l l tel l the assi stant team

6 leader, who tells me over the radio that medical confirms the
7 state of unconsci ousness.

I a Rnd then the execution would proceed?

9 At that point, then flê, jn my role as team leader,
A
1-0 wjll djrect the assistant team leader to proceed then to Phase
II IWO.

LZ MR. EVANS: Thank you. No further quest'ions.

1-3 THE couRT: okay. cross?
t4 MR. TYE: Good mornìng, Your Honor. r'm Michael Tye

1-5 for Mr. uowel I .

16 CROSS-EXAMINATION

L7 BY MR. TYE:

l-8 a cood mornì ng, Mr. Cannon.

1-9 A Good morn'ing.

20 a Mr. cannon, are you a medical doctor?

2L A No, si r.
22 a Do you have any medical train-ing?
23 A No medical trainìng other than the training that r
24 have as a certified correctional officer in reference to cPR

25 and fi rst responder trai nì ng.

061
 L78

1 a Do you have any specìfic trainìng to determine

2 any spec'ifì c medi cal trai n'ing to determi ne whether someone i s
3 consci ous?
4 A only that trainìng that you receive in basic life
5 support or cPR, as far as the shake-and-shout and those kjnd
6 of procedures.
7 a Do you have any trainìng to determine whether
8 someone is in a comatose state?
9 A No, sjr.
1-0 a Do you have any traìn'ing to determjne whether
1-1- someone is jn a surgical plane of anesthesia?
L2 A NO.

1-3 a Do you have any trainìng to determine whether

L4 someone who is unconscious strike that. Do you have any

1-5 traj n-ing to determi ne whether someone i s unconscious such that

1-6 when a noxious stimuli is applied they won't be aroused?
L7 A As far as trainìng, the only training r've had is
1-8 from the medical professionals on the team in what to look for
l-9 as those th'ings are applied and then throughout our trainìng
20 jn the actual train'ings where r have practiced those exercises
2L or those stimuli on a conscious person and seen their reactjon
22 to it. Numerous times, r've had that.
23 a Rnd do you rely on any kind of monitor to determjne
24 whether the person is conscious or is it solely the
25 consciousness check you described?

062
 L79

1- A As r described to Mr. Evans, the medical

2 professionals in the back, they have the monjtors and they
3 rely on the monjtors in makìng their determination. My
4 determination is made on those noxious stimuli tests that r do
5 and the shake-and-shout.
6 a Rnd what kind of monitors are there?
7 A rhe moni tors they have i n the back?
I a Yes.
g A To my knowl edge what they have i s, fi rst of al I
,

i-0 just a camera that's trained on the face of the inmate where
l-1- they can see any reactions to those tests that I do, as well
LZ as their EKG monitor that is hooked to the inmate's chest.
l-3 a Rnd the EKG monitor measures heart rate, is that
L4 your understandìng?
15 A r'm not sure what all ìt measures, but, Y€s, sir,
l-6 heart rate for sure.
L7 a Are there any monitors to measure brain actjvity?
1-8 A Not to mY knowl edge.
1_g a Are there any monìtors to determine any kind of
20 medical data other than the EKG monitor you mentioned?
2L A Not to my knowl edge, ho, si r.
ZZ a Rnd during the executìon, I thìnk you mentioned that
2i it's you specifìca'l1y that performs the consciousness check?
24 A Yes, si r.
25 a rs there anyone else involved in the process?
063
 180

i_ A Not in the consciousness check other than those

2 persons I described that's observìng and in the back of the
3 room, jn the back with the executioners, that then confjrms
4 that.
5 Q Rnd r think r mentioned when you did the
6 conscjousness check, YoU stroke the inmate's eyelashes, ìs
7 that correct?
8 A Stroke the i nmate's eye'lashes , j ust depressi ng the
9 jnmate's eyelashes, to see if there's any kind of reaction to
1,0 that eyel i d or eye-lash , Y€s , si r.
1-1- a Rnd how much pressure do you apply?
t2 A I can, I guess, show you. I don't know really how
1-3 to describe, but just a little firm touch on the eyelìd.
L4 a nnd djd you receive any trajnjng wìth respect to
1-5 what pressure to aPPIY?
16 A Agaìn, only from the medical professionals on the
L7 team, as we discussed that and they showed me how to do that
j-B and what to look for. Rnd then the actual times of doìng jt
L9 many tjmes on a conscious person and see'ing what their
20 reacti on was.
2t a Rnd I think you mentjoned that at some po'int you
22 shake the i nmate?
23 A Yes.
24 a Rnd could you show us what type of pressure you
25 apply when you're shaking the jnmate?
064
 181

1 A okay. r just reach over the jnmate and get both

2 shoulders and shake them v-igorously and shout their name.

3 a h/hen you do the consciousness check, do you do

4 anything else than what you've mentioned here today?
5 A Just those three that r described.
6 a So you don't gìve the inmate any smellìng salts?
7 A No, si r,
I a Rnd you don't use any kind of clamp or anything like
9 that when you're performing a consciousness check, js that
1_0 co r rect?
1_L A Not a clamp other than my hand and my fingers on the
L2 t rapezo'i d pi nch .
1_3 a Are you familiar with the september 9, 20L3,

L4 protocol for executions?

l_5 A Yes, si r.
1-6 MR. TYE: Rnd this has previously been admjtted âs,
L7 r believe, Defendant's Exhibit uumber 4. rf r could
l_8 approach and provide it to the witness?
1-9 THE couRT: Do you have that, Madam clerk?

20 THE CLERK: I believe Your Honor does.

2L THE COURT: Okay. You're sure that that's the same

22 copy?

23 MR. TYE: It's the same, Y€s.

24 THE COURT: Okay.

25

065
 L82

1 BY MR. TYE:

2 Q could you poìnt me to where in the protocol it

3 instructs you how to perform the consciousness check?
4 A rt will take me a second to find where it actual]y
5 talks about jt, but I'll go ahead and tell you before I find
6 it that jt does not talk spec'ifically how jt's performed, jt
7 just says that a consciousness check will be performed and I
I will then confer with medical, who will advise of their
9 fi ndi ngs.
10 Do you sti I I need me to fi nd exactl y what i t says?

1-L a Yes, if You could, Please.

LZ A on Page 10, Number 4, c4, "At thjs poìnt, the team
L3 warden will assess whether the inmate is unconscious. rhe
L4 team warden must determine after consultation that the inmate
15 is indeed unconscious. rf the inmate is unconscious and the
L6 team warden orders the executioners to continue' the
t7 executioner shall proceed to step 6."
1_g a r notice jt didn't mention anything about the eye
1-9 flick or shak-ing the inmate or any of the things you talked
20 about. rs that correct?
2L A Yes, si r.
22 a So none of that stuff is in the written protocol?
23 A No, si r.
24 a How di d you know how to do those thì ngs then i f i t's
25 not in the written Protocol?
066
 183

L A I started bei ng when I was asked to be the

when
2 team warden over thjs process, r was sent to Terre Haute,
3 rndjana, to train with the Federal Bureau of Prisons and
4 observe thei r trai nì ng and thei r protocol s. Rnd i n doì ng
5 that, they d'id the shake and shout. That's the only
6 consciousness check that they dìd at the time.
7 Rfter coming back from there and conferring with our
8 medical professionals, we made a decision that we add the eye
9 flick to that at that time. Rnd r will stop here and say that
1_0 r can assured'ly tell you that this team is aware of the
11_ evolvìng standards of decency and our object'ive is a d'ignifjed
L2 and humane death. so there are some thìngs that we have
1_3 changed during these seven years to try to ensure that, that
L4 we've kept up wìth technologY, that we've done those kind of
1_5 thì ngs.
1_6 Rnd then later we added the trapezo'id p'inch as a
L7 part of the consciousness check to ensure we were taking every
l_8 precaution we possibly could to ensure that the person was, in

1_9 fact, unconsci ous.

20 a Rnd do you recall when you added the trapezoid (sic)
2L pi nch?

22 A rhe trapezo'id p'inch was added before the Muhammad

23 executi on.
24 a gefore the ¡¡uhammad execution?
25 A That's correct.
067
 184

1- a why dìd you feel the need to add the trapezoid

2 pi nch?
3 n Aga-in, to make sure that this process was humane and
4 dign'ified. Rnd in read'ing some of the news media reports and
5 see'ing some of the expert testimony in reference to this
6 subject, we just felt like an additional safeguard would be a
7 good th'ing to add to make sure that we were hunane and
I di gnì fj ed.
9 a Rnd if jt's not written in the protocol, ìs it at
1-0 your sole discretion how the conscjousness check is performed
11- during each individual execution?
LZ A As the team leader, I'm obviously over everything
1-3 associated with that execution. But I wouldn't say my sole
L4 discretion because r do confer with the medical professìonals
l-5 on the team to make any suggesti ons.
1_6 One that thi ng that's spel l ed out i n the poljcy i s

L7 that anyone that's a part of the team, i f they see anythi ng

l-8 they feel like could make this process more humane and
1-g dìgn'ified or to keep up w-ith evolvìng standards of decency or
20 technology, then they're able to voice that. Rnd at each
2L debriefing I stress that to the team. And we have changed
22 numerous thìngs, numerous thìngs jn relatjon to that.
23 one of the thìngs that r have dictated js that every
24 team member has to serve in that role as the condemned durìng
25 trainìng at some point. We've changed several aspects of just
068
 185

1_ the comfo rt I evel fo r the i nmate whi I e 1 ay'i ng on the gu rney .

2 Maybe we put sponges under the hand or padd'ing under the hands

3 to it more comfortable, changed the pillow, the angle of

make

4 thìngs, just things to try to make it a little more

5 comfortable, more humane and d'ign'ified as we move a1ong. Rnd

6 this fell into that same category.

7 a But, u1t'imatel y, you ' re the one responsi bl e for
I performìng the consciousness check?
9 A rhat is correct.
1_0 a Rnd if you deviated in any way from what you just
1_ 1_ described, there would be nobody else to halt the execution,
L2 i s that correct? ul ti matel y, i t' s your cal I ?
1_3 A r'm not sure r really understand the question.
1,4 a Ultimately, is there anyone else you have to report
15 to after that or is it your decision that the consciousness
1_6 check has been made and it's sufficjent? rs there anyone else
L7 you need to report to at that po'int?
1_8 A wel I , -it's j ust I i ke the procedu re di ctates . rt' s
l_9 my respons'ibiljty to do those first three checks r described
20 and then to confer with medica-I, who is doìng the things that
2L they do before we make that determination that he is, jn fact,
22 unconsci ous.
23 THE couRT: Excuse me just a mjnute. r don't know

24 who you three people are jn the back, but ìf you're going
25 to remain jn here you need to stop smacking gum and

069
 186

L sm'i rkìng and making faces. rf you do it, any three of

2 you do it or anyone else in the courtroom does it agaìn,
3 you're going to be asked to immediately leave.
4 Rnd r do mean you, sir, in the tan suit. r know

5 you're maki ng a face I i ke you haven't done anythi ng I i ke

6 that, but you need to stoP.
7 UNIDENTIFIED SPEAKER: I'm sorry.
I THE couRT: okay. Go ahead.
9 BY MR. TYE:

1-0 a rhank you, Your Honor.

l-1 you mentioned the other medical members of the team.
L2 Can you describe for me where, physìca11y, they're located?
1-3 A They're located near the executioners, behind the
L4 window in the executioners' room. rhey're watching that
l-5 camera r described, that monitor, and the monitors on the EKG.
1-6 rhey would be standìng approxìmately two to three feet from
L7 whe re r 'm standi ng w'i th the condemned . Rnd they ' re watch'i ng

1-8 that process as well.

1-9 a Just so r make sure r clear, in the room
have this
20 with the inmate, there's you and there's the inmate. rs there
2L anyone el se i n the room at that tj me?
22 A There's an ìndependent monitor from FDLE that is
23 assigned and statjoned in that room. Rnd then r have one more
24 of my team members in that room that operates the microphone
25 and the window coverìng to the gallery.

070
 L87

1 a And then ìn the room where the medical team members

2 are, the peop-le you've described as medical team members, who
3 else is in that room?
4 A rhe assjstant team leader,
5 fun. EVANS: Your Honor, t'm going to object. I
6 thi nk we're getti ng way beyond the scope of di rect at
7 thi s stage.
8 THE coURT: What's your response to that, Mr. rye?

9 MR . TYE : tve ' re desc ri b-i ng he re the consci ousness

1-0 check and we're just trying to get a sense of the room
1-1- and what kind of procedures are taken.
L2 rhey went way beyond just a sìmp'le question wjth
1-3 respect to the consciousness check. r mean, w€ don't
L4 have a sense of where everybody is standing.
l-5 THE couRT: Al I ri ght. r'l I overrul e the objection.

16 why don't you ask h'im again?

t7 THE WITNESS: PIeASE.

1.8 BY MR. TYE:

1-9 a Yes, I was just askìng, in the room where the

20 additional team members are, outside the executjon chamber,

2L who is in that room and where are they standing?

22 A okay. First of all, you have the two executioners
23 in that room. one executioner is actually carry'ing out the
24 duties of an executioner for that particular execution. rhe
25 other is on stand-by in case that one is rendered unable to

071
 188

1- continue for any reason.

2 you have the assistant team leader. You have three
3 medi cal profess'ional s who are moni tori ng the thi ngs r
4 described to you. You have another ìndependent FDLE monitor.
5 and then r have two more team members that are respons'ib1e for
6 maintainìng the open line to the governor's office and
7 relaying things to the governor's office.
8 a Rnd you mentioned this consciousness check that you
9 perform. rs that the sole conscjousness check that's
1-0 performed or is there any other consciousness check that's
1-1 performed throughout the proceedìng, or throughout the
LZ execution?
1-3 A At the end of phase one, before we proceed to phase
L4 Two, we perform that consciousness check, as we descrjbed,
l-5 both myself and the medical professìonals.
1-6 a But that's the sol e consci ousness check?
L7 A rhat i s i t, y€s, si r.
l-8 a thank you. you sajd you were told what to look for
19 when the second and third drugs are administered, r believe.
20 A r don't think r said that.
2I a rn terms of the patient or in terms of the inmate.
22 Do you know what the second drug does?
23 A r don't think r said that r was told what to look
24 for when the second and thjrd drugs were administered. r
25 don't remember us talking about that at all. But r do know
072
 189

1 what the second drug is and what that does, Y€S, sir.
2 Q okay.

3 a rt's vecuronium bromide and jt's a paralytic.

4 a Rnd you menti oned medi cal professì onal s on the team.
5 Could you name them?
6 A No, sir.
7 MR. EVANS: Your Honor, I'm going to object. rhis
8 does go far beyondthe relevance and there's a statute
9 that p rohi bi ts the di scl osu re of thei r i denti ti es .
1-0 MR. TYE: You don't have to name them by name, but
LL r'm just tryìng to get a sense of what their
L2 qualificatjons are and
L3 THE couRT: r 'm go-ing to sustaj n the obj ecti on . So

L4 ask him something else.

]-5 BY MR. TYE:

1-6 a so you menti oned thi s consci ousness check you

L7 perform. Rnd r guess you've said that the p'inch was just
1-8 added in the ¡¡uhammad executjon, is that correct?
1-9 A rhat is correct.
20 a rhe other pìeces of the consciousness check you
2L mentioned, do you do the same thing in every executjon?
22 A Yes, sj r.
23 a and you mentioned in the other room there's the
24 person who's jn charge of dispensing the chemicals that are
25 ultjmately that ultimately go into the inmate's body?
073
 190

l_ A rhe executioner?
2 a n'ight.
3 A YES.

4 a Do you know who's in charge of mixing the chemicals?

5 MR. EVANS: You r Honor, I thì nk th j s i s go'ing way

6 beyond the scope. we limited it to the consciousness

7 test. hte di dn 't say anyth'i ng about the mi xtu re , the
I test, and i denti fyi ng any of the peopl e i nvol ved. Agai n,
9 it violates the statute.
1_0 MR. TYE: we're not asking to ìdentify them by name
1_ 1_ or even we're just asking who's in charge of mixing
L2 the chemicals. r mean, this has been at issue throughout
13 this proceedìng. Several wjtnesses have testifjed about
L4 thi s preci se i ssue.
L5 MR. EVANS: Rnd, your Honor,r think it, agaìn, goes
1_6 beyond and if someone would bother to look at the
L7 protocol, r think the protocol indicates who's
1_8 responsi bl e.
1-9 TYE: Your Honor, we know what the protocol
MR.
20 says, but we want to know in practice how this js
2L actually done. Rnd there's no other way for us to obtajn
22 thi s i nformation.
23 THE COURT: okay. r'm goìng to overrule, ìf you can
24 answe r that wi thout d j scl os'i ng the i denti ty of anybody ,

25 Mr. Cannon

074
 191

1_ THEWITNESS:Wouldyouaskthequestionagain'
2 p1 ease?

3 BY MR. TYE:

4 a who's i n charge of mi xi ng the chemi cal s?

5 rhe procedure dictates that the persons that have to

A
order, ma-intaì n, and mi x the chemi cal s come f rom two
cl asses
6

7 of trained professionals, either a doctor, a physician, or a

I pharmacìst. And we do comply with that procedure'
9 aDoyouknowifit'sadoctororpharmacìstwho
1_0 pe rfo rms

l_l_ MR.EVANS:Objection,YourHonor'rhatgoesback
t2
1_3 THEcoURT:I'mgoingtosustajntheobjection.
t4 BY MR. TYE:

l_5 aDoyouknowwherethedrugsareobtainedforthe
l_6 executi on?
L7
ect. hle
MR. EVANS: You r Honor, I'lTl goi ng to ob j

1_8 asked about the consciousness test' rhe i ssue

of the
1_9 drugs never have come into thìs' r di dn't ask anYth'ing
20 about those.
2L THEcoURT:I'mgo.ingtosustajntheobjectìon.
22 rhis jsn't a dePosìtion, MF'TYe'
23 BY MR. TYE:

24 aMovingbackto,Iguess'the2ot3protocol,whichis
25 1n frontofyou,'ifyoucouldlookatPagerbelieveit's3
075
 t92

L of the protocol.
2 A Yes s'l r.
3 a Excuse me, Page 4.that portjon of the protocol
Rnd

4 mentj ons vari ous traj n'i ng actj vi ti es that are done wi th

5 respect to the executjon, is that correct?

6 A YES.

7 a Rnd if you look sort of a third of the way down the

8 page, I bel j eve i t' s under trlumber C
9 A 4C.

1_0 a yes. rt mentions that one of the trainìng

4C,
1_ 1_ exercises is if the inmate is not rendered unconscious after
L2 the administration of midazolam hydrochloride.
1-3 A Yes, sir.
L4 a Have you ever been involved in a trainìng with
15 respect to what to do when an individual is not rendered
1_6 unconscious with respect to mjdazolam?
L7 A Yes, si r. As the pof i cy spe1 1 s out, that's one of
1_8 our contingenc-ies that we do train for. rhe way our pof icy js
1_9 written and what we train for is if, in fact, we've done the
20 consciousness check and the inmate was not unconscious' then
2L my role as team leader would be announce to the gallery that
22 the execution had been temporarìly suspended, close the window
23 coveling to the gal I êrY, and ask for the medi cal profess'ional s
24 to come out , check the 'i n I the
j ecti on si tes , l ook at al

25 equipment, and make a determjnatjon of what they felt like

076
 193

L caused the inmate to not lose consciousness.

2 rf , i n thei r dete rm'i natì on , they dec j ded the re was
3 something wrong, faulty equìpment, a faulty stick, or whatever
4 the case may be, then we would reevaluate that, move to the
5 alternate sjte, and restart the process, beginning over with
6 Phase one.
7 a Rnd jn that sectjon it mentjons there's a wrjtten
I record. rt says there shall be a written record of any
9 t rai n'i ng acti vi t j es . rs a wri tten reco rd kept of such
10 trajning activities?
1- 1_ A Yes, si r.
L2 a Do you know where such written record can be
1_3 obtai ned?
L4 MR. EVANS: J udge , r 'm go'i ng to ob j ect agai n .

1_5 THE COURT: Sustained.

1-6 BY MR. TYE:

L7 a Have you ever heard the term "paradoxical reactjon?"

1_8 A No, si r.
1_9 a Have you ever recejved any trainìng on what to do if
20 a patient or an inmate experiences a paradoxical reaction?
2L A No, si r.
22 a were you involved at all in the were you involved
23 at all in the comìng up wìth the 201-3 protocol? t^/ere you
24 involved in the actual putting together of the protocol?
25 MR. EVANS: Your Honor, r'm gojng to object again.

077
 L94

1 r asked about the consciousness test, not the putting

2 together of the protoco'l .

3 THE couRT: okay. r'm going to sustain the

4 obj ect'ion .

5 ev N4n. TYE:
6 a Were you involved at all wjth respect to the
7 creation of the consciousness check in the 20L3 protocol?
8 MR. EVANS: Your Honor, r think he indicated
9 THE couRT: Yes , r ' tTl goi ng to ove r rul e any ob j ecti on

1-0 on that. He's al ready sajd he was' You can ask him a
LL couple follow-up questìons on that, if you want, Mr. Tye.
L2 BY MR. TYE:

1-3 a ouring your consultatjons in the creation of the

L4 protocol, did anyone mentjon paradoxìca1 reactions?
1-5 A No, si r. when you asked that questì on , i nvol v'i ng i n
1-6 a lot of that, I'ln not sure I understand really what you're
L7 aski ng.
1-8 a when the protocol was created, djd anyone
l-9 spec'if j cal l y consi der whether someone coul d be aroused when
20 they're unconscious by a noxious stimuli?
2t A Not that r'm aware of.
22 a Do you know why rlorida decjded to use the drug
23 mi dazol am?
24 A No, si r.
25 a Going back to the setup of the execution room, is
078
 195

1- there ever a sheet over, p'laced over the inmate's body?

2 t rn every executjon, there js a sheet placed over the
3 i nmate' s body. rhat sheet i s spec'ial 1y cut and desi gned to
4 cover the jnmate's feet, legs, and torso; exposes both
5 i nmate's arms and from the neck up.
6 a Rnd is that sheet always placed over the inmate in
7 the same way?
I A Yes, si r.
9 MR. TYE: Your Honor, if r can have a couple of
l-0 mi nutes to consul t.

1-L THE COURT: Okay.

L2 MR. TYE: Thanks. (pnUSe)

1-3 rhank you, Your Honor. tì/e have noth'ing further '
L4 THE COURT: okay. Thank you.

l-5 Any di rect?

1-6 REDIRECT EXAMTNATION

L7 BY MR. EVANS:

1-8 a Now, your role is to check for consciousness during

1-9 thi s porti on of the procedu re , j s that correct?
20 A That's correct.
2L a Now, the pressure you apply, the eye flick, is that
22 suffi ci ent to gaì n a response?
23 A rt has always gained a response from a conscious
24 person duri ng the trai nì ngs.
25 MR. TYE: objection, Your Honor. That's beyond the

079
 196

L scope of direct, beyond the scope of cross. we weren't

2 allowed to get into that.

3 THE COURT: Overruled.

4 BY MR. EVANS:

5 Q You were asked to give the example of the shakìng.

6 A Yes.

7 a Rnd the shouting. rs that gìven to a degree djd

8 you actually shake the witness stand when you were showìng how
9 you shake
10 A erobab'ly so. certainly the inmate is shaken. r can

l-l- tel I you that.

L2 a Rnd the pinch pressure po'int, when you do the

L3 pì nchì ng, do you do i t suffj cj ent to gai n that woul d

L4 jnflict pa'in on a person who was conscious?

1-5 A Rbsol utely.

1-6 a Rnd while you may not know the term paradoxìca1
L7 effect or noxious stimuli, it js your role to do procedures to
L8 see whether or not someone is conscious and is aware of pa'in,
1-9 is that correct?
20 A Yes, sj r.
2L MR. EVANS: Thank you.
further questions.
No

22 THE coURT: Okay. Does he need to remai n avai]ab]e ,

23 Mr. Evans?

24 MR. EVANS: No, YOur HOnOr.

25 THE COURT: Mr. rye?

080
 L97

L MR. TYE: No, Your Honor.

2 THE COURT: Okay. You're free to 90, Mr. Cannon.

3 thanks.
4 okay. so, 'it's a couple of minutes after 12:00. So

5 y'all don't have your next wjtness is not available

6 unti 1 5:00, j s that ri ght?
7 MS. MILLSAPS: That is rìght, Your Honor. Dr.
I Dershwitz is doìng rounds.
9 THE COURT: Okay. nnd r had had counsel for the

1_0 newspaper, Ms. Fugate, oh stand-by for this afternoon.

11 Can r go ahead and tell her that you're releasing the
L2 reporter from the subpoena, MF. ufferman?
1_3 MS. SENN: Can we have a moment, Your Honor?
L4 THE COURT: Okay. You guys can discuss that a

1_5 mi nute.
1_6 (pnuse)

L7 that's correct. there

MR. UFFERMAN: Your Honor,
1_8 were actually four reporters and r think the attorney for
1_9 the reporters represents all four. nnd, y€s, they're all
20 four released from the defense.
2L THE coURT: Okay. So I'll go ahead and let

22 Ms. Fugate know that and know that she does not,
23 obviously, need to be available because those subpoenas
24 are bei ng rel eased.
25 Can you guys thi nk of anyth'ing el se that we are

081
 198

1_ going to need to address prìor to hearìng from Dr.

2 oe rshwi tz?

3 MR. UFFERMAN: NO, YOUr HOnOr.

4 MR. EVANS: NO.

5 THE CoURT: So why don't we come back at quarter

6 till 5:00, just to make sure in case something comes up.
7 Rnd r'l I pl an on that. rf somethi ng unexpected comes up

I before that, r'ln going to be in my office. so if we

9 needed to use the ti me for anyth'ing , we certai nl y coul d.
1_0 r wi I I be around, so p'lease contact me ì f anyth'ing comes
11 up.

L2 otherwjse, if r don't hear from you guys, r'll see

r-3 you at quarter till 5:00. okay?

L4 MR. UFFERMAN: tl/e'll be in the same courtroom, Your

L5 Hono r?

1_6 THE COURT: Same, Y€S.

L7 MR. UFFERMAN: Thank You, Your Honor.

L8 THE COURT: Okay. thanks.

L9 (necEss)

20

2L

22

23

24

25

082
 199

L CERTIFICATE

2 STATE OF FLORÏDA:

3 COUNTY OF LEON:

4 I, EUGENIA B. LAWRENCE, Registered Professjonal

5 Reporter, do hereby certi fy that the forego'ing proceed'ings
6 were taken before me at the time and place therein designated;
7 that my shorthand notes were thereafter translated under my

I Supervi s'ion; and the foregoì ng pages are a true and correct
9 record of the aforesaid proceedìngs.
1_0 I FURTHER CERTIFY that I am not a relative,
L1_ emp'loyee, attorney or counsel of any of the parti es , nor
L2 relative or employee of such attorney or counsel, or
13 fi nanci al l y j nterested i n the forego'ing acti on '
1,4
DATED thi s daY of 20L4.
1-5

1_6 E'.*-r*t^cr*-
EUG rA B. LAh/RENCE, RPR
L7 OFFICIAL COURT REPORTER
LEON COUNTY COURTHOUSE
18 TALLAHASSEE, FLORIDA 32301-

19

20

2L

22

23

24

25

083
 IINTTED STATES DISTRTCT COURT
MIDI}LE I'ISTruCÎ Otr FIÍ}RIDA
JACI(SOTWILLE DIVISION

ETHDRIA V. JACKSON, )
)
Plal¡tilf, ) C¡¡eNo: 3:14-cv-01I49-MMH-JBT
)
)
v8. ) IDeatù Peneþ Cmc
) Iqf unctlve Rellef Sought
JOEN PALME& tn hl¡ oflicÍ¡l caprcÍúy as )
lhc Wsrdctr of Floridr StNtc Prbotr, )
MICIIABL It. CREITS¿In hb ofñcirl capaelty )
¡r the Secretary, Floddr llcpartmcnt of )
Corrscflonc, )
)
Defendant¡. )
)
)
I

AFFTDAVTT OT AICTIARD KILEY

t. I am Richard Kiley and I am curcntly emptoycd âs ar asomçy at Capihl Collaterâl

Rcgional Cor¡nscl - Middle Region (CCRGM). I h¡ve bæn an attomey for 27 ycars and

bave been ernploycd ¡t CCRC-M for 13 years.

2, Aspartofmydutiæ, I witrcssdüc exocutionc of Martin G¡oss¡¡ran on February 16,2010,

Darir¡s Mark Kimb¡u¡gh on Træsda¡ Novcmbcr 12,20'!,3,md Ëddie ttrayne Drvis on July

10,2014.

3. For Mr. Kimbrough's cxecution, at 6:00 p.m. tüc cr¡rtain went up. Mr. Kinhrougb uras

lying zupine. I was scatcd in tbs ûont row ofths wiûræs viewiag roorr.

4' fn the room with Mr. Kimbrougb werc ttrroe ottrcr pcople - a man rtcxt to Mr. Kimbrougþ

a man in the comor of the room on my lefr a¡d a woman in the room ûo my right sidc.

084
 14-6 Filed LilaLlL4 Page 3 of 5 PagelD 492
case 3:14-cv-01149-MMH-JBT Document

5. Mr. Kimbrough was covered from his shoulders to his feet in a white sheet and covered

from his neck to his chin by a white paper bib.

6. The sheet was not draped ovet the body, but instead appeared to be tented over Mr.

Kimbrougþ such that you could not observe any movemcnt of Mr. Kimbrough underneath

the sheet.

7. This was different than the previous execution of Martin Grossman that I had observed

where the sheet was draped normally over him and you could see his chest rise and fall

underneath the sheet.

B. Iür. Kimbrough's bare arms protruded from the sheet and I could see tubes protuding from

his right arrn. Due to the placement of the gumey, I could not see his lefr arm.

9. His rigbt hand appeared to be balled into a físt and was wrapped tightly with ace bandages

so I could not see his hand, nor af,y movements his hand may have been making.

10. At 6:01 p.m, the man next to ì[r. Kimbrouglr asked him if he had any last words' lvfr,

Kimbrough did not offer a final st¿tement'

l l. At 6:05 p.m., the man next to Mr. Kimbrough lifted Mr. Kimbrough's left eyelid twice' I

could observe no reaction from Mr. Kimbrough. The man then lifred Mr. Kimbrough

slightly by the shoulders and let hirn fall back. I could observe no reaction by M¡.

Kimbrough.

12. Due to the tented sheet, I was unablc to observe Mr. Kimbrough's chest rising and falling,

or any other movement he may have been making. Because of the tenting of the sheet, any

movement would have been irnpossible to see.

085
Case 3:14-ar-01149-MMH-JBT Document 14-6 FiledL2|OUL4 Page 4 of 5 PagelD 493

13. At 6:77 p.m. the man next to Mr. Ki¡nbrouglr pickcd up the wall phone and said something

into it. A man in a white lab coat and white latex gloves then appeared from bchind a

curtain in the area bchind Mr. Kimbrough's head.

14. He produced a pçn light and checked M¡. Kimbrough's left eye first, then the right. He

tlren rcmoved the white paper bib from Mr. Kimbrough's neck and produced a stethoscope

from the pocket of his lab coat. He procoeded to check both sides of Mr. Kimbrough's

neck and said something to the man next to Mr. Kirnbrough. The man in the white lab coat

then exited ttrougb the same curtain from which he entered.

15. The man next to Mr. Kimbrough then flicked on an intprcom switch and stated that the

sentence was executed at 6:18 p.m.

16. Other than at the beginning when the man asked if t\,fr, Kimbrough had any last words and

the end where he announced that the sentence had been ca¡ried out, the intercom in the

execution chamber was h¡med offand I could not hear anything from the chamber.

17. For the Davis execution, at 6:30 p.m., the rüarden asked if hír. Davis had any last words.

Mr. Davis did not offer a final statement.

18, From 6:30 p.m. to 6:33 p.m., Mr. Davis appeared to be praying. As with the Kimbrough

execution, once the 'Ûfarden tumed off the microphone afte¡ offering the opportunity for

the final stâtement, I could not hear anything going on inside the chamber.

19. From 6:33 p.m. to 6:36 p.m., I obse,rred Davis' head tilt back and his mouth opening and

closing in a tortured grimace.

20. From 6:36 p.m. to 6:40 p.m., there was no movement. A man in a white lab coat carne out

and checked Davis' neck and eyes. He had what appearcd üo be an animated convcrsation

086
Case 3:14-cv-01149-MMH-JBT Document 14-6 Filed !2l0LlL4 Page 5 of 5 PagelD 494

with the Warden, which I could not hedr. The Warden then pronounced the time of death

at6:43 p.m. and the curtains were immediately lowered.

21. Unlike in the Kimbrough execution, in Mr. Davis' execution, the Wardcn did not conduct

a conssiousness check at any point during the exccution. He did lean over Mr. Davis at

one point, but the Warden did not touch Mr. Davis, shake him, tap his eyelids, or pinch his

trapezius. Because there is no sound in the charnber, I cannot be certain whether he cslled

his name or not, but I am certain he did not physically touch Mr. Davis at any point during

the execution.

FURTHER AFFIANT SAYETH NAUGHT.

//ê
RICIIARD KILEY

SWORN TO AIID SUBSCRIBED TO before me, RICIIARD KILEY, on rhis

4o who is personallyknown to me.
Ieuv of

CARLOS RODRIqJE:¿III
ømm¡Un*ff 0æ¡17
NOTARY OF FLORIDA Ërú¡¡ ftntltg,2017
loi.l tuf,nY-f ¡ mnt ¡c'¡on

087
STATE OF FLORIDA
COUNTY OF LEON

COMES NOW THE AFFTANT, NEAL A, DUPREE, WHO, IJNDER THE PENALTY OF
PERIURY, HEREBY STI/EARS AND AFFIRMS AS FOLLOWS: ,

I . My name is Neal A. Ðupree, and I have been a licensed Ftorida attomey since 1980. I cunently
serve as the Capital Collateral Regional Counsel for South Florida" and I have held that position
since August, 1998.

2. During my tenure as Capital Collateral Regional Counsel-South (CCRC-South), my offroe

reprcsented Cary Michael Lambrix durÍng his post-conviction appeals. It was in my capacþ as
CCRC-South that I witnessed the execution of Mr. Lambrix at Florida State Prison on October 5,
20t7.

3. OnOctober5,20lT,inaccordancewithFloridaDepartmentofCorrections'procedure,Ianived
at the administation building ofthe Florida State Prison at 4:00 p.m. I waited in the administration
building until approximately 5:30 p.m. During that time I hád my office cellular phone with me
and was able to remain in constant contact with the legal team representing Mr, I¡mbrix. As I left
the administration building to go ínto the Florida State Prison to witness the execution, I was
informed by Florida Department of Corrections personnel that I would not be allowed to take my
cellularphone into the prison. From 5:30 p.m. until -9:30 p.m. all witnesses to the execution of Mr.
Lambrix, other.than the press, were kept in the chapel of the Florida State Prison. During that four
hour period I was unable to contact Mr. Lambrix's legal team.as I had no access to my cellular
phone. However, I observed at least one Florida Department of Concctions'employee who was
also a witness to the execution using a cellular phone during the time the witnesses were confined
to the chapel. It was only after the execution that I had access to my cell.ular phone. I was also
denied access to my celtular phone during the executions I witnessed prior to Mr. Lambrix.

4. During my tcnure at CCRC-South I have also witnessed the executions of Angel Diaa lVayne
Tompkins, Manuel Valle, and ManuelPardo.

5. The execution of Mr. Diaz occuned on December 13, 2006 using a three drug cockail of
Sodium Thiopental, Pancuronium Bromide, and Potassium Chloride: The e¡ecutign of M¡.
Tompkins used the same drug cocktail as Mr. Diaz. However, the Florida Department of
Corrections used a different initial drug on Mr. Valle and Mr. Pardo, Pentobarbital instead of
Sodium Thiopental. The Florida Department of Corrections used yet another initial drug in the
execution of Mr, Lambrix, This time Etomidate was used as the initial drug instead of Midazolam.
The second and third drugs were also new as of 2017, using Rocuronium Bromide and Potassium
Acetate.

6. In addition to changing the types of drugs used in executions since. Mr. Diaz, the Florida
Departnent of Conections has also changed the physical location of the defendants in the

088
P520
execution chamber since his execution. This change obsoures the ability of witnesses to the
execution to obsorve the execution procedure as clearty as wa¡¡ observed during lhe execution of
Mr. Diaz.

7. During the execution of Angel Diaz on December 13, 2006, I was seated in the fronl row of the
observation room. I was located approximately 6-7 feet from Mr. Diaz who was laying on a gumey
covered by a white sheet perpendicular to my position.

8. I was able to obsprve that Mr, Diaz was smpped to a gurney and his right arm was held in place
by a leather strap. Mr. Diaz had some typc of ape or gauz€ holding his right hand in place and an
intravenous needle had been placed in his right arm where his elbow would bend.

9. From my positior¡ I had an unobstructed view of Mr. Diazls face, right arm, right side, and part
of his right hand. From my vantage point f could also clearly see the inüavenous line attached to
his right arm. I could see the tethal drugs flowing through the tubing. I could also see his fingers.

10. On October 5, 2017 ,l was again seated in the front row for the execution of Mr. Lambrix. The
cuftains to the execution chamber were opened at approxirirately 9:55 p.m. As opposed to the
execution of Mr. Diaa Mr. Lambrix was not placed in the same position as Mr. Diaz. Where Mr.
Diaz was perpendicular to my position in the front row giving me an unobstructed view ofhis face;
right side of his body, including the insertion site; and right hand, Mr. Lambrix was strapped to
the gurney with his feet pointed directly towards me.

I L
From the placement of Mr. Lambrix on the gurney I was only able to observe his face and 15-
l8 inches of each arm where an intravenous line had been inserted. Because of the dislånce,I
could not see the lethal drugs flowing through the tubing. Mr. Lambrix was.covered by a sheet
and his hands and fingers were completely covered up to his wrists with what appeared to be a
giant mitten making observation of his hands impossible. There was nothing completely covering
Mr. Diaz's right hand during his execution leaving his hand partially observable for the witnesses.

12. In addition, instead of being able to observe the fase of Mr. Lambrix from 6-7 feet away as I
had with Mr. Diaz, the new placement of Mr. Lambrix in the execution chamber meant I had to
observe his face from approximately 13-15 feet away. And, instead of a direct unobstructed view
of Mr, Lambrix's face, like I had of Mr. Diaz, I had to look over Mr. Larnbrix's feet and his oovered
body in order to see his face.

13. Mr. Lambrix was asked if he had any last words and he said part of The Lord's Prayer. The
execution proceduie commenced at about 9:56 p.m. For six minutes afrer the execution procedure
began I was able to see Mr. Lambrix breathe heavily. During this time I also observed his lips and
chin shudder in a rhythmic pattérn.

14. Aftcr approximately seven minutes I observed Ricky Dixon, Deputy Secretary of Institutions
for the Florida Department of Corrections, lean over Mr. Lambrix, brush his left eye, then grasp

089

P521
bqth of Mr. Lambrix's shoulders and shake him repeatedly. He also appeared to speak to Mr.
Lambrix. The witnesses cannot hear any sounds,coming from the chamber afte¡ the last words
are spoken, but I could see Mr. Dixon's lips moving.

15. Mr. Lambrix had no responsé to the actions of Mr. Dixofi. Seven to eight minutes later I
oþsprved a person Weering medical garb enter the exesution chamber, Hê placed a stethoscope on
lvfr. Lambrix s chest and shined a light into Mi: L¡mbrix's left eye. He then spoke to Mr. Dixon
and Mr. Larnbrix was pronounced dead at 10:10 p.m.

NAUGHT

A.

SV/ORN TO Al.{D SUBSCRItsED TO before me this /c& day of Oc(o\-etzr20l7, by Neat A.

Dupree, who is personally known to me, or produoed the following identiñcation
Ft f,t s O¡Ao - bzt- s.s:- Itç- O

STATE OF FLORIDA
My Expires:
laYg)xsmtt¡oil
GGi{6r2

090
P522
 SUBJECT: PAGE OF 19
STATE OF OHIO Execution
NUMBER: 01.COM.11

RULE/CODE REFERENCE: SUPERSEDES:

oRc 2949.22:2949.25
01-COM-1 1 dated 01/09/1 5

RELATED ACA STANDARDS: EFFECTIVE DATE:

June 29,2015
DEPARTMENT OF REHABILITATION
AND CORRECTION APPROVED:

L AUTHORITY

This policy is issued in compliance with Ohio Revised Code 5120.01 which delegates to the Director of
the Ohio Department of Rehabilitation and Correction the authority to manage and direct the total
operations of the Department and to establish such rules and regulations as the Director prescribes.

II. PURPOSE

The purpose of this policy is to establish guidelines for carrying out a court-ordered sentence of death.

uI. APPLICABILITY

This policy applies to all individuals involved in carrying out a court-ordered death sentence in
u.rotáunr. wiih all applicable policies, administrative regulations, and statutes.

IV. DEFII\ITIONS

Auxiliarv Tea.m Member - A physician, advanced level provider or registered nurse who has been
designated b¡r the Director to provide advice and consultation as described in this policy.

Critical Incident Debriefing Team - A group selected by the Warden, and including the Religious
etoassistanypersonsinvolvedintheexecutionprocess.A
psychological debriefing process is available via DRC clinical staff and others to recognize stressors
associated with executions and to work through them with affected staff as follows:

. Worker's own experiences of the execution including reactions and perceptions.

o Review any negative aspects and feelings.
o Review añy positive aspects and feelings,
o Relationships with workers and/or family.
o Empathy (sharing) with others
o Disengagement from execution experience.
o Integ¡ation of this experience into the profqssional work, role for a positive future
contribution to the overall team effort.
o Exploring religious cônvictions and feelings.
DRC 1361
091
SUBJECT: Execution PAGE 2 OF 19

Death lþuse - A physical location within the Southern Ohio Correctional Facility (SOCF) used for the
execution of a death-sentenced prisoner.

Death Row - (l) A housing area at the Chillicothe Correctional Institution (CCD or Ohio State
Penitentiary (OSP) that has been designated by the Director of the Department of Rehabilitation and
Correction to house male prisoners who are committed to the Departrnent with a sentence of death; (2)
A housing area atthe Ohio Reformatory for Women (ORW) that is similarly designated to house female
prisoners committed to the Deparrnent with a sentence of deatb (3) A housing area at the Franklin
Medical Center (FMC) that has been designated by the Director of the Department of Rehabilitation and
Correction to house male or female prisoners whose medical needs are inconsistent with assignment to
CCI, ORIW, or OSP pursuant to Department Policy 68-MED-13, Medical Classification; or such other
facility as may be deemed appropriate by the Director. Death Row is also a reference to a housing status
for prisoners sentenced to death; it is not a security classification.

Director - As used in the policy, the term "Director" refers to the current Director of the Ohio
Department of Rehabilitation and Correction or the Director's designee.

DLIIS Administrator - Any qualified member of the Medical Team who administers any execution drug
or witnesses the preparation and administration of any execution drug. A Drug Administrator shall be
currently qualified under Ohio Law to administer and prepare drugs for intravenous injections. A Drug
Administrator may also establish, or assist in, establishing, or assess, IV connections.

Elgcution Team - A group consisting of no less than twelve (12) members designpted by the Warden of
the Southern Ohio Conectional Facility to carry out court-ordered executions. Their dutics also include
preparation and testing of equipment, carrying out pre- and post-execution activities, and counseling
with the prisoner.

Execution Timeline - A record of events before and during an execution to include the specific
information required to be recorded by this policy aird other information at the discretion of the
Execution Team.

Medical Team Member - A person who is a member of the Execution Team and who is currently
quattfied under Ohio Law to administer and prepare drugs for intravenous injections, or who has at least
one year experience âs a certified medical assistant, phlebotomist, EMT, paramedic, or military
corpsman, or who is currently. certifïed or licensed within the United States as a registered nurse or nurse
practitioner

Relieious Services Administrator (RSAI - The Religious Services Adminisffator is the coordinator and
administrator for religious services for the Ohio Department of Rehabilitation and Correction (DRC).
The RSA will provide counseling and support services for the offender and others consistent with the
provisions of this directive.

Reprieve - The posþonement of an execution.

Stav'- A court-ordered suspension or postponement of a legal execution.

Suúooft Sfaff - Support Staff shall mean those individuals who have specified roles in this policy
including, but not limited to, medical staff, mental health staft Health Care Administrators (HCAs),
DRC 1362
092
SUBJECT: Execution PAGE 3 OF 19

appointed designees, correction ofücers at DRC institutions, the RSA, SOCF Chief of Security or
hislher designee, SOCF Deputy \üarden(s), the Special Assistant designated in this policy, and/or other
leneral DRC staff. Support Staff are not members of the Execution Team. Overhead management staff
at DRC are not Support Staff, and not members of the Execution Team. As defined above in this section
IV, only those individuals designated by the Warden to carry out court-ordered executions shall be
Execution Team members. The Director and the Warden(s) are not members of the Execution Team.

Warden - As used in the policy,

the term "'Warden" refers to the current'Warden of the Southern Ohio
Correctional Facility (SOCF), or his or her current Deputy ÏVarden, or the Director's designee, unless
the policy uses language which indicates another Warden of another institution.

V. POLICY

It is the policy of the Ohio Department of Rehabilitation and Correction to carry out the death penalty in
a constitutional manner and as directed by Ohio Courts of Law. All execution processes shall be
performed in a professional, humane, sensitive, and dignified manner. It is the responsibility of the
birector to designate a penal institution where death sentences shall be exêcuted. The Warden of that
facility, or Deputy Warden in the absence of the Warden, is responsible for carrying out the death
sentence on the date established by the Ohio Supreme Court.

The procedures set forth in this policy are to be strictly followed. Any situation that arises that would
make following these policies difficult, impractical, or impossible shall be immediately reported to the
Director or the lV'arden. Any variations of a substantial nature must be approved by the Director as
described in this policy.

There will be no variations from the following requirements:

t. At least three Medical Team Members, two of whom are authorized to administer drugs under Ohio
law, shall be used in the conduct of court-ordered executions.

2. The drugs required by this policy shall be used.

3. Functions required to be performed by medically-qualified persons, as described in this policy, shall
be performed by Medical Team Members.

4, All Execution Team functions shall be performed by appropriately trained and qualified members of
the Execution Team.

5. 'variation
Only the Director can authorize a variation from the procedures stated in this policy but not a
from the four requirements listed immediately above in subsections V.1.2.3. and 4. of this
policy.

VI. PROCEDT'RES

A. General Guidelines

1 All prisoners sentenced to death by a court of law shall be transported to a reception

center within the Department of Rehabilitation and Conection for initial processing.
Upon completion of the reception process, the prisoner shall immediately be transferred
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to the designated institution: CCI or OSP for male prisoners or ORW for female
prisoners. The Director may designate FMC or another appropriate DRC institution as
necessary.

2 All court-ordered executions shall be carried out at the Southern Ohio Correctional
Facility and will be planned to commence at 10:00 a.m. on the scheduled execution date,
subj eci to developing circumstances.

J Unless otherwise designated by the Director/designee, the prisoner shall remain on Death
Row until transferred to the Death House for scheduled execùtion.

4. The Ohio Supreme Court shall designate the date of execution. Upon receipt of a
scheduled execution date, the TVarden of the institution housing the.prisoner shall notiff
the Director, the RSA, and the Warden at SOCF.

5 Attendance at the execution is governed by Ohio Revised Code section 2949.25 and
includes:

a. The V/arden or Acting Warden of the institution where the execution is to be

'Warden
conducted and such number of correction officers or other persons as the or
Acting Warden thinks necessary to carry out the death sentence.

b. The sheriff of the county in which the prisoner was tried and convicted.

c. The Director of the Department of Rehabilitation and Correction, or designee, and

any other person selected by the Director/designee to ensure that the death sentence is
carried out.

d. Any Auxiliary will be to provide consultation or advice as

Team Member whose role
may be necessary. An Auxiliary Team Member shall attend such number of
execution rehearsals as the Warden may consider necessary, but no less than one
rehearsal per execution. An Auxiliary Team Member shall attend training sessions on
topics identified in subsection VI.B.4.b. of this policy, below. An Auxiliary Team
Member shall not.be required to attend an execution, but may, at the discretion of the
Warden, attend an exeCution and provide consultation or advice to the Warden, the
Director and the Medical Team.

e. The prisoner may select one or two of the fotlowing persons: the RSA, minister-of.
record, clergy, rabbi, priest, .imam, or regularly ordained, accredited, or licensed
minister of an established and legally cognizable church, denomination or sect,
subject to the approval of the Warden.

f. Three persons designated by the prisoner who are not confined in any state institution
subject to the approval of the Warden or Acting Warden based on security
considerations. The prisoner may also request that one or two attorneys attend the
execution.

g. Three persons designated by the immediate family of the victim,subject to the

approval of the Warden or Acting Warden based on security consideration, as

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detailed in Department Policy 03-OVS-06, Victim Involvement in the Execution

Process.

h. Representatives of the news media who are authorized by the Director, which may
include representatives of the following: a newspaper, a television station, and a
radio station.

6. Given the gravity of the sentence to be carried out, it is imperative that these procedures
be strictly adhered to and all actions by Department personnel in carrying out the
sentence be fully documented as required by this poticy. However, due to the difñcult
and sometimes r.rnpredictable nature of the tasks to be performed in carrying out the
sentence it may noì always be possible to follow these procedures to the letter. Thus,
variations from the requirements of the policy directive may sometimes be necessary.
Any Support Staff, overhead management staff at DRC, or member of the Execution
Toam who determines for any reason it is difTicult, impractical, or impossible to strictly
follow the procedures in this policy directive'shall immediately report the same to the
Warden or to the Director. The Director may then consult with the Warden and others as
appropriate. Only the Director may authorize a variation from the procedures in this
policy directive. Any such variation shall be documented as soon as possible.

8.. Execution PreparatÍon - Approximately thirty (30) days prior to the scheduled execution
date

1. Notification

The Warden of the institution where the prisoner is housed shall notify the Director of an
upcoming scheduled execution date. Notifrcation may also be provided to the
supervising Regional Director of SOCF, DRC Chief Counsel, DRC Managing Director of
Operations, the Adult Parole Authority (APA), the Ohio State Highway Patrol
@ortsmouth and Jackson); and the Office of Victim Services.

2. Execution Drugs

a. The Warden shall determine whether there will be sufficient quantities of the
execution drugs available for the scheduled execution and report those findings to the
Director.

b. The Warden's assessment of what constitutes a sufficient quantity of execution drugs

shall include ensuring a sufficient amount for a contingency against contamination or
inadvertent loss.

c. At his discretion, the V/arden may, at any time, direct the Health Care Administrator,
the Health Care Adminisfator's designee, or SOCF's responsible pharmacist, to order
execution drugs from a licensed pharmacist at the Office of Support Services of the
Ohio Departnnent of Mental Health and Addiction Services, from a pharrnacy,
manufacturer, supplier or distributor, or from any other licensed pharmacist.

d. All execution drugs delivered to SOCF shall be maintained in a Secured location.

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e. If compounded execution drugs are to be used, a sample from the batch of those drugs
will be analytically tested before they are used. The sample will be tested for identity
and potency, pursuant to the applicable USP/Ì'{F monograph. DRC will only use the
batch of compounded drugs if its sample is properly identified as the intended drug
and its tested potency is within the applicable monograph standard. At the discretion
. of the Director, a sample of nor-compounded execution drySs iraV also be tested for
identity and potency pursuant to the applicable monograph standard.

3. Assessment of Prisoner

Every possible effort shall be made to anticipate and plan for foreseeable difficulties
^. in establishing and maintaining the intravenous (IV) lines. The prisoner shall .be
.evaluated by appropriately trained medical staff approximately twenty-one (21) days
prior to the execution to evaluate the prisoner's veins and plan for the insertion of the
IV lines. This evaluation shall include a "hands-on" examination as well as a review
of the medical chart to establish any unique factors which may impact the manner in
which the Execution Team carries out the execution. Potential þroblems shall be
noted and discussed, and potential solutions considered, in advance of the execution,
Concerns or potential issues shall be communicated to the Warden or designee at
SOCF as soon as þossible. None of the fr¡nctions described in this subsection shall be
governed by subsection V.3. of this policy, above.

b. Any evaluation that is conducted by medical staff pursuant to subsection VI.B.3.a. of

this policy, above shall be noted in the prisoner's medical chart.

c. The prisoner's medical condition shall be assessed in order to identifu any necessary
accommodations or contingencies that may arise from the prisoner's medical
condition or history. Any medical condition or history that may affect the
performance of the execution shall be communicated as soon as possible to the
Warden of SOCF, who shall confer with others as necessary to plan such
accommodations or contingencies. The fact of the assessment and any conclusions
shall be documented in the prisoner's medical chart. None of the functions described
in this subsection shall be governed by subsection V.3. of this policy, above.

d. Any concerns for establishing or maintaining tV lines and any concerns or plans for
medical açcommodations or contingencies shall be communicated to the Execution
Team in order that these things may be discussed and addressed in execution trainings
or rehearsals.

e. An appropriate member of the mental health søff shall evaluate the prisoner
approximately twenty-one (21) days prior to the execution to evaluate his or her
stability and mental health in light of the scheduled execution. Any concems or
contingencies affecting the execution process shall be communicated to the Warden
of SOCF as soon as possible. The fact of the assessment and any conclusions shall be
documented in the prisoner's mental health record. None of the functions described in
this subsection shall be govemed by subsection V.3. of this policy, above.

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f. Beginning approximately thirty (30) days prior to the scheduled execution date until
the prisoner's transfer from Death Row to SOCF, the prisoner shall be evaluated by
mental health staffto determine the prisoner's appropriate observation level, housing
status and access to personal property. None of the functions described in this
subsection shall be governed by subsection V.3. of this polic¡ above.

4. Training

a. The Execution Team shall begin conducting training sessions no less than once per
week until the scheduled date of execution. The training shall address any
aocommodations or contingencies that might be anticipated.

b. Training in the following topics shall be provided for every member of the Execution
Team, and any Auxiliary Tear.n Member designated by the Director; prior to service
and at least once per year thereafter:

The general nature and effects of the execution drugs that are used during the
execution process;

ii. Drug administration procedures, includiqg the insertion of the IV needles and
administration of inj ections;

iii. Signs or symptoms of problems when administering drugs; and

iv. Any legal developments of significance.

5. Other Preparations

a. The RSA shall make contact with the prisoner to establish counseling and family
contact information

b. Prior to commencement of the initial training session, the Warden or the Team Leader
shall verify and document the qualifications of the Medical Team members. Medical
team members shall provide evidence of certification status at least once per year and
upon any change in st¿tus.

c. The Team Leader shall ensure that each member of the Execution Team has received
a copy of the current version of this execution policy. Each member of the Execution
Team shall sign for its receipt.

C. Execution Preparation - Approximately fourteen (14) days prior to the execution

The \r¡/arden of the institution where the prisoner is housed shall have the Execution
lnformation Release (DRC1808) completed by the prisoner. This form will veri$
information on the prisoner, visitors,. witnesses, spiritual advisor, attorney, requested
wibress, property, and funeral arrangements.

2 The names of official witnesses/media witnesses shall be supplied to the Warden, as

outlined in this policy.
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J The names and relationships of the victim's witnesses shall be supplied to the Warden.

4 The RSA shall provide family information from the prisoner to the rüarden.

5 Approximately fourteen (14) days prior to the execution, the Warden shall determine
whether a sufficient quantity of pentobarbital (urder whatever name it may be available
from a pharmacy, manufacturèr, supplier, distributor, pharmacist, or compounding
pharmacy) or a suffrcient quantity of thiopental sodium (under whatever name it may be
available from a pharmacy, manufacturer, supplier, distributor, pharmacist, or
compounding pharmacy) is available for use at the scheduled execution.

a. If a suffrcient quantþ of pentobarbiøl or thiopental sodium is available, then the

scheduled execution shall proceed with intravenous administration of either
pentobarbital or thiopental sodium, as determined by the lVarden, in accordance with
the terms of this policy.

b. If a sufficient quantity of pentobarbiøl or thiopental sodium is not available, or if at

any time the available pentobarbital or thiopental sodium is deemed unusable by the
Medical Team, then the'Warden shall consult with the Director and they shall notiff
the Governor.

c; Notice of the Warden's determination, concerning the selection of execution drugs or

insuffrcient quantities of such drugs to be used for intravenous administration, shall
be provided to the prisoner.

d. If the scheduled execution date is posþoned for any reason, and:

such posþonement is less than ten (10) days, then no later than four (4) days prior
to the re-scheduled execution date, the V/arden shall make the determination set
forth above in subsection VI.C.S. of this policy.

ii. such posþonement is between ten (10) and thirty (30) days, then no later than
seven (7) days prior to the re-scheduled execution date, the Warden shall make
the determination set forth above in subsection VI.C.S. of this policy.

iii. suoh posþonement is more than thirty (30) days, then approximately fourtÞen
(14) days prior to the re=scheduled execution date, the Warden shall make the
determination set forth above in subsection VI.C.5. of this policy.

e. The Warden shall ensure that sufficient quantities of the execution drugs, which have
been determined to be used for the scheduled execution, have been delivered to SOCF
and stocked within an appropriate secured location and then noti¡/ the Director.

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D. 'Execution Preparation - Approximately twenty-four Q4) hours prior to the scheduled

execution

1 The prisoner shall be transferred from Death Row and housed in the Death House at
SOCF. The prisoner shall be constantly monitored by at least three (3).members of the
Execution Team. An Execution Timeline shall be maintained.

2. An Authorized Independently Licensed Mental Health Professional shall interview the

prisoner periodically and submit progress reports to the Warden. All prisoner files shall
be maintained in the Vy'arden's office at SOCF, unless otherwise directed by the Warden.

3 The V/arden shall establish a line of communication with DRC legal staff and the
Attomey General's Office for notice of case status and/or other significant legal changes.

4 The RSA shall provide counseling and spiritual support unless the prisoner requests not
to have such contact.

5 Beginning with his/trer arrival at SOCF, the prisoner shall not be forced to meet with non-
staff visitors that he or she does not wish to see.

E. Execution Prepaiation - The following events shall take place upon the prisoner's arrival at
the Death House

l. Once the prisoner is at SOCF, the Death House shall be restricted to the following:

Director/desi gnee(s) ;
Warden;
Mernbers of the Execution Team;
Managing Directors or Regional Directors;
Communications Chief/designee ;
Institution Deputy Warden;
Administrative Assistant to the Warden;
Chaplain;
Physician;
Independently Licènsed Mental Health Professional;
Chief of Security;
Maintenance Superintendent;
Any other person as deerned necessary by the Warden.

2. The prisoner shall be evaluated by medical staff on the day of arrival at SOCF to evaluate
the prisoner's veins and plan for the insertion of the IV lines. This initidl evaluation shall
include a "hands-on'? examination as well as a review of the medical chart. At a
minimum, a "hands-on" oxamination shall also occur later that evening. Potential
problems shall be discussed, and potential solutions considered. The perforrnance of
these two evaluations shall be noted in the Execution Timeline. Any relevant portion of
the medical file may be kept in the Death House for appropriate reference as needed.
None of the functions described in this subsection shall be governed by subsection V.3.
of this policy, above.

DRC f362
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SUBJECT: Execution PAGE 10 - 19

3 SOCF chaplains shall imake periodic visits to the prisoner, if requested by the prisoner.

4 The Deputy Warden shall assign security personnel to staff entrances, checþoints, and to
assist the Ohio State Highway Patrol (OSHP).

5 The Team Leader shall ensure that the prisoner's property is inventoried in front of the
prisoner. The prisoner will have previously, pursuant to subsection VI.C.l. of this policy
above, specified who is to receive his or her personal effects. The Team Leader shall
ensure that the Inmate Property Record Disposition and Release @RC2055), correctly
specifies this information, and the Team Leader shall sign it to confirm the review.

6 The prisoner shall, pursuant to subsection VI.C.1. of this policy above, specify in writing
his/her request for funeral arrangements, which shall be recorded in the Execution
Information Release, (DRC 1 808)

7 The prisoner shall be allowed contact visits with family, friends and/or private clerg¡ as
approved by the Warden, between approximately 4:30 p.m. and 7:30 p.m. on the day
prior to the scheduled execution. If the prisoner requests an attorney meeting, the
prisoner shall be allowed one confidential attorney-client meeting, not to exceed an hour,
on the day prior to the execution, following the prisoner's intake at SOCF. This visit will
take place in an af,ea where conversation is not audible to DRC staff. The visit will be
visually monitored and recorded on video only. Before such meeting, all attomeys shall
be subject to a thorough, gender-specific search of their person and property. Cell front
visits as approved by the Warden shall be permitted between approximately 6:30 a.m,
and 8:00 a.m. on the day of the scheduled execution. The attorney and spiritual advisor
may continue to visit with the prisoner until approximately 8:45 a.m. The Warden may
modiff the frèquency and duration of the visiting opportunities at his or her discretion.

8. The Team Leader shall ask the prisoner to identiff his or her special meal re{uest. The
special meal shall be served the day prior to the scheduled execution at a time to bç
determined by the Warden.

9 The Warden shall brief key personnel, to include medical and mental health staff, in order
to allow intake information to be obtained.

10. The V/arden shall receive updates from security personnel and the OSHP on crowd
conhol, demonstrations, pickets, etc.

11. The Chief of Security or designee shall brief the Warden on the level of tension within
the remainder of the prison population.

12. The Warden shall relay any out of the ordinary activity to the Regional Director
supervising SOCF.

13. The Execution Team shÊrll continue to prepare as needed.

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F. Execution Preparation - Morning of Execution Day. At any time, as determined by the

Team Leader, on the morning of the execution:

1 The prisoner shall be permitted to take a shower and dress in the designated clothing the
morning of the execution.

2. Vein Assessment

A "hands-on" examination of the prisoner's veins shall be made by a Medical Te4m

Member before the IV is established. If any potential problems are identifïed they shall
be discussed between the Mçdical Team, the Warden, the Director, and any Auxiliary
Team Member, and potential solutions shall be considered. The performance of this
evaluation shall be noted in the Execution Timeline.

3. Possession of Execution Drugs

A Drug Administrator, in the presence of a second Drug Administrator, shall take

possession of the execution drugs from the SOCF responsible pharmacist or another
appropriately licensed pharmacist at the secured pharmacy storage area, and shall
document possession of the drugs by signing form Order for Execution Medications
(DRC2001). The Drug Administrator taking possession of the drugs, accompanied by a
second Drug Administrator shall deliver the drugs to the Death House. These persons
shall complete form Order for Execution medications (DRC2001).

4. Drug.Preparation

a. The drugs shall be prepared for injection by a Drug Administrator. The preparation of
the drugs shall be monitored by a second Drug Administrator who shall
independently verifu the preparation and dosage of the drugs. Both Drug
AdminiStrators shall complete form Order for Execution Medications (DRC2001).

b. If the 'Warden determines that a sufficient quantity of pentobarbital is available and

. has been selected to be used, then a Drug Administrator shall prepare the execution
drugs as follows:

i. Syringes I and 2: Five (5) grams of pentobarbital, 100 ml of a 50mg/ml solution,

shall be withdrawn and divided into two syringes labeled "1" and"2".

ii. Syringes 3 and 4: Five (5) additional grams of pentobarbital, 100 ml of a

S0mg/ml, solution, qhall be obtained and kept available in the Equipment Room,
but need not be withdrawn into syringes unless the primary dose of five grams
proves to be insufficient for the procedure. These two additioqal syringes labeled
"3" and "4" shall be kept available for contingent uso.

c. If the Warden determines that a sufficient quantity of thiopental sodium is available

and has been selected to be used, then a Drug Administrator shall prepare the
execution drugs as follows:

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SUBJECT: Execution PAGE 12 OF 19

i. Syringes l, 2, 3,4 and 5: Five (5) grams of thiopental sodium, 200 ml of a

2lmglml solution, shall be withdrawn and divided into five separate syringes,
labeled "1","2","3",('4" and "5".

ii, Syringes 6,7,8,9 and l0: Five (5) additional grams of thiopental sodium,200 ml
of a 25mglml solution, shall be obtained and kept available in the Equipment
Room, but need not be withdrawn into syringes unless the primary dose of five
grams proves to be insufficient.for the procedure. These five additional syringes
labeled "6","7","8","9" and "10" shall be kept available for contingentuse.

d. The drug preparation shall be documented as follows:

i. The Drug Administator who prepared the execution drugs and the Drug
Administrator who witnessed the preparation shall complete form Order for
Execution Medications (DRC200 1).

ii. A Drug Administrator shall inform the Command Center when the Execution
Drugs are prepared, and the Command Centershall record in the Execution
Timeline the time that the drugs were prepared.

5 Official witnesses to the execution will report to the institution. The victim's witnesses
shall report to the Portsmouth Highway Patrol Post, or other Post or location designated
by the Highway Patrol, for escort to the institution by designated SOCF personnel.

6 The prisoner shall be allowed to have visits as described in subsection VI.E.7. of this
policy, above.

7 The RSA shall be present to counsel and provide spiritual support to the prisoner and
staff.

8 Allcommunication equipment shall be tested, including primary and secondary

communication, with both the Governor's Office and the Office of the Attomey General.

a. Primary communications shall be via a telephone line opened directly to the

Command Center from the execution chamber. This line shall be tested one (1) hour
prior to the scheduled execution. Other than testing, this line shall remain open.

b. Secondary communications shall be via cellular telephone.

c. In the event that both the primary and secondary communications are inoperable, the
execution shall be delayed until communications are established.

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G. Execution Preparation - Approximately fifteen (15) minutes prior to the scheduled

execution

1. Wiüresses Transported to Death House.

All authorized witness groups shall be escorted to the Death House separately by
designated staff. Witnesses shall be escorted to viewing rooms before the death warrant
is read.

2. Phone for Prisoner's Counsel

If the prisoner chooses to have his or her counsel as a witness, at all times after counsel
enters tle wiuress room, counsel shall have free access to the phone near the entrance
door of the Death House.

a. The phone in the Death House foyer will enable counsel to call into the waiting room
for prisoner's counsel in the prison compound where another person, whose prosence
is arranged by counsel for the prisoner and whose presence satisfres tþe prison's
security concerns, and which person is acting on behalf of the prisoner and his or her
counsel, will be situated during all times after the death warrant is read.

b. The Warden shall allow this other person to have access to his or her own laptop
computer and to a phone that can connect that person to an outside line.

3 Death'Warrant

The V/arden shall read the death wa¡rant to the prisoner.

4 Closed-Circuit Camera Activated

Immediately after the death warrant is read, the closed-circuit camera in the execution
chamber shall be turned on so that witnesses in the witness rooms can view the
subsequent activities in the execution chamber on the television screen in those rooms.

5. Prisoner Enters Execution Chamber

The rWarden and Execution Team shall escort the prisoner to the execution chamber,
assist the prisoner onto the bed and secure the shaps. The team shall roll up the prisoner's
sleeves or take other steps to ensure that the anns are ptainly visible to persons in the
chamber and to those in the equipment room.

6. Curtain Closed

Once the prisoner is secured to the bed, the curtain shall be closed prior to the insertion of
the IV needles. The closed-circuit camera shall remain on to allow the witnesses to view
the establishment of IV site(s).

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SUBJECT: Execution PAGE 14 OF 19

7 IV Site(s) Preparation & Establishment

a. The Medical Team shall enter the Execution Chamber to prepare IV site(s).
b. The Medical Team shall establish one or two viable IV sites.

i. The ann veins near the joint between the upper and lower arrn shall be utilized as
the pieferred site for the IV injection.

ii. In the event that the Medical Team member is unable to establish an [V at a
prefened site, thE Medical Team member(s) may establish an IV at altemative
site(s) for use by the Drug Administrator when administering execution drugs.

iii. The Execution Team may utilize any non-invasive device such as a light,
illuminator or ultrasound device, if desired, to assist in locating a vein.

c. The Medical Team member(s) shall be allowed as much time as is necessary to

establish viable tV site(s).

d. If the Medical Team mernber(s) are unable to establish viable IV site(s), the Medical
Team members shall consult with the Warden, the Director, and any Auxiliary Team
Member for the purpose of determining whether or how long to continue efforts to
establish viable IV site(s).

8. Confirming & Recording Establishment of [V Site(s)

A Medical Team member shall test the viability of the IV site with a low-pressure
^. saline drip through IV tubing. If necessary, a heparin lock may be attached to the IV
needle as an altemative to the saline drip.

b. The Warden, Team Leader, and a Drug Administrator shall all confirm the visibility
of the IV sites.

c. The Medical Team member(s) shall exit the Execution Chamber and shall announce
. the number of attempts made to establish viable IV site(s) to the Command Center
contact who shall then inform the Command Center, for capture on the Execution
Timeline.

d. The Command Center shall record in the Execution Timeline the number of attempts.

9. Curtain Opened

The.curtain shall be opened after fhe establishment of viable IV site(s). The curtain shall
remain open during the remainder of the execution until the examination for the
pronouncement of death, rlrless the execution is abandoned or halted.

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SUBJECT: Execution PAGE 15 OF 19-
10. Last Words

The Warden shall ask the prisoner if he or she has any last words. If the prisoner has a
last statement, he or she will be allowed to make it while the witnesses are present in the
adjacent viewing rooms, and are able to see him or her and hear him or her via
microphone

a. There shall generally be no restriction on the content of the prisoner's statement and
no unreasonable restriction on the duration of the prisoner's last statement.

b. The V/arden may impose reasonable restrictions on the length of the statement- The
Warden may also terminate a statement that he or she believes is intentionally
offensive to the witnesses.

H. Commenceiment of Execution

1. Execution by IV Injection

a. If the Wa¡den has determined, pursuan! to subsection VI.C.S. of this policy above, to
proceed with pentobarbital, then upon the Warden's signal, a Drug Administrator
shall intravenously adrninister the previously prepared syringes I and 2 of
pentobarbital.

b. Alternatively, if the Warden has determined, pursuant to subsection VI.C.5. of this

policy above, to proceed with thiopental sodium, then upon the Warden's signal, a
Drug Administrator shall intravenously administer the previously prepared syringes l,
2,3,4 and 5 of thiopental sodium.

c. The low-pressure saline drip shall be allowed to flush saline through the line(s)
following completion of the IV drug administration.

d. A second Drug Administrator shall be present in the equipment room to observe the
administration of the execution drugs. This Drug Administrator shall announce the
start and finish times of each injection to the Command Ceirter contact who shall then
inform the Command Center foi capture on the Execution Timeline.

e. The Command Center shall record in the Execution Timeline the start and finish
times of each injection.

f. Following administration of the IV drugs, a Drug Administrator shall reenter the

Fxecution Chamber to inspect the IV site for evidence of incontinence or infiltration
and to listen to the prisoner for breathing and heart sounds.

g. If a sufficient time for death to occur has passed brt the prisoner has not died, the
Medical Team shall consult with the Warden anif the Director, and any Auxiliary
Team Member. The Warden, after consultation with the Director, shall determine
whether to proceed with any additional syringes of execution drugs, and may order
the Medical Team to prepare such additional syringes, as necessary, and
intravenously administer them, in accordance with the terms of this policy, above.
DRC 1362
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SUBJECT: Execution PAGE 16 OF 19

h. At the completion of the process and after a sufficient time for death to have
occurred, the curtain shall be closed and an appropriate medical professional shall
evaluate the prisoner to confïrm death, The curtain shall then be re-opened and the
Warden shall announce the time of death. kr the event that the appropriate medical
professional cannot confirm that death has occurred, the curtain shall be reopened
until an appropriate time has passed to reevaluate the prisoner.

2. Using Alternative IV Sites

a. The Team Leader, a Medical Team member, and the Warden shall observe the
prisoner dwing the injection process to look for signs of swelling or infiltration at the
fV site, blood in the catheter, and leakage from the lines and other unusual signs or
symptoms.

b. The Execution Team shall communicate to the Drug Administrators. any problems
detected during the adminishation of the execution drugs.

c. The Drug Administrator who is administering the execution drugs shall determine
whether it is necessary to use another viable IY site.

d. In the event that the Drug Administrator who is administering the execution drugs
detects a problem in the administration of the drugs, the Drug Adrninistrator shall use
any other viable IV site. No prior consultation with the Warden or other members of
the Execution Team is required.

e. Whenever it is necessary to change fV sites, the Drug Administrator shall administer

a full dosage of the execution drug through the alternate, viable IV site using
additional syringes, as necessary,.prepared in accordance with the terms of this
policy, above.

f. In the event the Drug Administrator changes to another viable IV site, the Dntg
Administrator shall inform the Command Center contact, who shall then inform the
Command Center for capture on the Execution Timeline. The Command Center shall
record in the Execution Timeline any change in IV site(s).

3. Establishing Other IV Sites(s)

a. In the event there is no altemative viable fV site, the Medical Team shall consult with
the Warden and Director.

b. The Warden, following consultation with the Director, shall determine whether to
proceed with execution by IV injection

c. In the event the Warden determines to proceed ïith execution by IV injection, the
Execution Team shall repeat the steps in subsections VI.G.6. - 8. of this policy,
above, and continue ri'ith the execution as provided for in subsection VI.H. of this
policy, aboüe.

DRC 1362
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SUBJECT: Execution PAGE___ 17 0F 19

d. The Warden shall ensure the Command Center is informed of his decision. The
Command Center shall record the Warden's decision in the Execution Timeline.

I. Post-Execution

1 The Warden, or his designee, shall notify the Director that the execution has been carried
out.

2. The Medical Team shall remove the IV equipment and clean the [V sites

3. The RSA or the prisoner's Spiritual Advisor shall anoint the body of the prisoner if
requested by the prisoner.

4. The RSA shall coordinate the burial of the prisoner's body with local chaplains if the
prisoner's family does not want the body.

5 The Execution Team shall remove the deceased from the execution bed and place him or
:

her on a gurney.

6 Disposition of the body shall be in accordance with arrangements made prior to the
execution at the prisoner's request.

7 The \üarden shall sþ and return the death warrant to the Court, indicating the execution
has been carried out.

8. Prepared Execution Drugs

a. A Drug Administrator shall properly dispose of any execution drugs that have been
prepared for administration but not been utilized.

b. A Second Drug Administrator shall witness the disposal.

c. Both Drug Administrators shall document the disposal in form Order for Execution
Medications (DRC200 I ).

9. Unprepared Execution Drugs

a. A Drug Administrator shall properly return any unprepared execution drugs to the
secured pharmacy storage area.

b. A Second Drug Administrator shall witness the return of the unprepared execution
drugs.

c. Both Drug Administrators shall document the return of the unprepared execution
drugs in form Order for Execution Medications (DRC2001).

DRC 1362
107
SUBJECT: Execution PAGE 18 OF 19

10. Recording Used Execution Drugs

a. A Drug Administrator shall document the name or description, and any expiration
date or beyond use date, of the execution drugs used, in fonn Order for Execution
medications (DRC200 1).

b. An Execution Team member shall save the packaging of the used execution drugs or
take photographs of such packaging. None of the functions described in this
subsection shall be governed by subsection V.3. of this policy, above.

11. After-ActionR.eview

Immediately following an execution, the Execution Team and the on-site administrators
directly involved in the execution process shall meet to review the process of the
execution. Any unique o¡ unusual events shall be discussed, as well as opportunities for
improvement and successful procedures. Actions and documentation of the events shall
be reviewed to identify any discrepancies. Discrepancies. from the policy directive shall
be clearly described and noted in a written record. The record shall be signed and dated
by the Warden.

12. Critical Incident Debriefing

a. The 'Warden shall ensure that critical incident debriefings are available for the
Execution Team and staff participants immediately following the execution.

b. The Critical Incident Debriefïng team shall conduct interviews in accordance with
CIM guidelines.

c. The RSA shall be available for debriefing for the family of the prisoner.

13. Quality Assurance Review

The Director shall designate a Special Assistant for Execution Policy and
Procedures. The Special Assistant shall evaluate the performance of the Execution Team,
review the conduct of .court-ordered executions and report to the Director of the
Department. His or her duties will consist of reviewing documentation, training, and
professional qualifications, to ensure compliance with the written policy directive. The
Special As'sistant may utilize assistants as necessary to compile or assess the information,
and may consult with others consistent with the confidentiality of the process. Whenever
appropriate, the Special Assistant shall consult with a propgrly trained medical person
when reviewing the medical aspects of the execution procedures. The Special Assistant
wilt also provide consultation and advice concerning modifications in the written
directive. The Special Assistant will prepare a report to the Director following each
execution, with any suggestions or recommendations that are appropriate.

DRC 1362
108
SUBJECT: Execution PAGE 19 OF 19

Related Department Forms:

Execution Information Release DRCI808
Order for Execution Medications DRC2001
Inmate Property Record Disposition and Release DRC2055

DRC't362

109
 ARIZONA CHAPTER: 700 OPR:
DEPARTMENT
OF OPERATIONAL SECURITY OPS
CORRECTIONS

DEPARTMENT ORDER: 710 SUPERSEDES:

DEPARTMENT ORDER MANUAL EXECUTION PROCEDURES DO 710 (10t23t151

EFFECTIVE DATE:

JANUARY 11,2017

REPLACEMENT PAGE
REVISION DATE:

N/A

TABLE OF CONTENTS
PURPOSE

RESPONSIBILITY
pROCEDURES PAGE

710.O1 DIRECTOR'S OFFICE RESPONSIBILITIES - NOTICE OF FILED WARRANT OF EXECUTION....2

710.02 COMPLEX AND DIRECTOR',S OFFICE RESPONS|B|L|T|ES...... ..........2
710.03 EXECUTION TEAM MEMBERS ....................4
710.O4 COMMUTATION HEARING PROCEEDINGS 9
710.05 DESIGNATION OF WITNESSES BY DIRECTOR 9

710.06 STATE AND LOCAL LAW ENFORCEMENT BRIEF¡NG; SITE CHECKS 10

710.O7 THIRTY-FIVE DAYS PRIOR TO THE DAY OF EXECUTION - COMPLEX 11

710.08 THIRTY-FIVE DAYS PRIOR TO THE DAY OF EXECUTION - CENTRAL OFFICE 12

710.09 TWENTY-ONE DAYS PRIOR TO THE DAY OF EXECUTION - CENTRAL OFFICE 13

710.10 FOURTEEN DAYS PRIOR TO THE DAY OF EXECUTION - CENTRAL OFFICE 14

710.11 TWO DAYS PRIOR TO THE DAY OF EXECUTION 14
710.12 TWENTY-FOUR HOURS PRIOR TO THE DAY OF EXECUTION ............14
710.13 TWELVE HOURS PRIOR TO AND THROUGH THE EXECUTION 15

710.14 POST-EXECUTION ..........18

710.15 PROCEDURES FOR NEWS MEDIA .......... 19
IMPLEMENTATION...... ..........21
CROSS-REFERENCE INDEX ..........21
AUTHORITY ..........21
ATTACHMENTS

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DEPARTMENT ORDER: 710 EXECUTION PROCEDURES

PURPOSE
This Department Order establishes procedures for planning and carrying out the execution of a person convicted
of a capital offense and sentenced to death. These procedures shall be followed as written, except that the
Director of the Arizona Department of Corrections {Director) is allowed to make limited deviations from or
adjustments to these procedures when required to address certain unexpected or otherwise unforeseen
contingencies, subject to the limitations on the Director's discretion as set forth herein. Except as expressly
permitted herein, the Director shall not have any authority to deviate from or make adjustments to any material
aspects of the execution process, including, but not limited to, the execution chemicals or dosages,
consciousness checks, the access of the press and the inmate's counsel to the execution, and the timeframes
established by this Department Order. This Department Order outlines internal procedures and does not create
any legally enforceable rights or obligations.

RESPONSIBILITY
The Department ensures the execution of a person sentenced to death under State law by a court of competent
authority and jurisdiction is carried out in keeping with statute, case law and professional practices.

The Department shall make every effort in the planning and preparation of an execution to ensure the execution
process:

Faithfully adheres to constitutional mandates against cruel and unusual punishment.

ls handled in a manner that minimizes its impact on the safety, security and operational integrity of the
prison and the community in which it occurs.
Accommodates the public's right to obtain certain information concerning the execution.
Reasonably addresses the pr¡vacy interests of persons as provided by law.
Provides contingency planning to identify and address unforeseen problems.
Allows for stays of execution, commutations and other exigencies up to the time that the sentence is
imposed.
Provides opportunity for citizens to exercise their First Amendment rights to demonstrate for or against
capital punishment in a lawful manner.
Ensures there is an appropriate response to unlawful civil disobedience, trespass and other violations of the
law by any person attempting to interfere with the execution or the operation of the prison.

The Department shall detain, seek the arrest and encourage prosecution of persons whose conduct includes

I Violating prohibitions against filming, taping, broadcasting or otherwise electronically documenting the
execution of the inmate.
Trespassing and otherwise entering upon Department property without authorization.
Participating in unlawful demonstrations or unlawfully attempting to disrupt, prevent and otherwise interfere
with the execution.
Unlawfully threatening, intimidating and otherwise attempting to influence authorized persons involved in
the execution process.
These prohibitions apply to the inmate population as well as department personnel and members of the
general public engaging or attempting to engage in disruptive and other prohibited behaviors.

Participating staff shall adhere to the Department's Code of Ethics and Guided Principles, evidencing

Appropriate levels of professionalism, restraint and courtesy when interacting with witnesses,
demonstrators, attorneys, news media, state and local law enforcement and any other member of the public
directly and indirectly involved with the imposition of the sentence of death.
All assigned duties are performed proficiently and professionally.

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Their ability to exercise the opt¡on to withdraw from the process by the prescribed means at any time.
Conduct that appropriately reflects the solemnity of the activities in which they elect to engage and the
duties they choose to perform.
Reserving public comment on any and all facets of the execution except as expressly provided in
Department Order #2O1, Legal Services - lnformation Release.
Any Department employee who learns of identifying information regarding any person who participates in or
performs any function of an execution must keep that information confidential.

IMPORTANT GUIDELINES REGARDING CONFIDENTIALITY AND VOLUNTARINESS OF PARTICIPATION IN AN

EXECUTION:

The anonymity of any person, as defined in A.R.S. t 1-215(28) and A.R.S. 5 13-105(30), who participates
in or performs any ancillary function(s) in the execution, including the source of the execution chemicals,
and any information contained in records that would identify those persons are, as required by statute, to
remain confidential and are not subject to disclosure. A.R.S. E 13-757(C).
All team members serve on a strictly voluntary basis. At any point before, during or after an execution any
team member may decline to participate or participate further without additional notice and explanation or
repercussion.
The Division Director for Offender Operations shall ensure all team members understand and comply with
the provisions contained herein.

PROCEDURES
710.O1 DIRECTOR'S OFFICE RESPONSIBILITIES UPON NOTICE THAT THE STATE HAS FILED A
MOTION FOR WARRANT OF EXECUTION

1.1 Upon notice from the Attorney General's Office that it has filed a Motion for Warrant of
Execution in the Arizona Supreme Court:

1.1.1 General Counsel shall

1.1.1.1 Notify the Director, Division Director for Offender Operations, the
Wardens of ASPC-Florence and ASPC-Eyman or ASPC-Perryville, and
the Media Relations Director.

1.1.1.2 Notify the Victim Services Team Leader, who shall contact the
victim(s) and inform them that the State is seeking a Warrant of
Execution.

1.1.2 The Director shall notify the inmate and the inmate's counsel in writing of the drug
protocol that will be used in the event a Warrant of Execution is issued and lethal
injection is the method of execution.

710.O2 COMPLEX AND DIRECTOR'S OFFICE RESPONSIBILITIES UPON RECEIPT OF WARRANT OF

EXECUTION

1.1 Upon receipt of the Warrant of Execution from the Attorney General's Office

1 .1.1 General Counsel shall:

1.1.1.1 Notify the Director, Division Director for Offender Operations, the
Wardens of ASPC-Florence and ASPC-Eyman or ASPC-Perryville, and
the Media Relations office.

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1.1 .1.2 Forward the original Warrant of Execution to the Warden of ASPC-
Florence.

1.1.1.3 Forward copies of the original Warrant of Execution to the Warden of

ASPC-Eyman or ASPC-Perryville.

1 .1 .1.4 Notify the V¡ctim Services Team Leader, who shall contact the
victim(s) and inform them of the court's issuance of the Warrant of
Execution.

1.1.2 The Director shall

1.1.2.1 Select the time of execution and provide notice to the Arizona
Supreme Court and the parties at least 2O calendar days prior to the
execution date. (Arizona Rules of Criminal Procedures, Rule
31 .1 7(c)(3))

1.1.2.2 Notify the inmate that ¡f the offense was committed prior to
November 23, 1992, the inmate shall choose in writing using the
Method of Execution, Form 71O-1, either lethal injection or lethalgas
at least twenty-one days prior to the execution. lf the inmate fails to
choose either lethal injection or lethal gas, the penalty of death shall
be inflicted by lethal injection (A.R.S. 5 13-757(B)).

1.1.2.3 Have the authority, under exigent circumstances, to change the

timeframes established in this Department Order in order to address
certain unexpected or otherwise unforeseen contingencies.

1.1 .3 The ASPC-Eyman or ASPC-Perryville Warden shall:

1.1.3.1 Direct the inmate to submit the lnmate Witness and Notification
lnformation, Form 71O-2, to the Warden no later than 14 days prior
to the scheduled execution date.

1 .1 .3.1 .1 lnform the inmate that two clergy and five other
persons may be invited to be present at the execution.

1.1.3.1.2 Notify the inmate that minors are prohibited from

witnessing the execution pursuant to A.R.S. 5 13-
758.

1 .1 .3.1 .3 Notify the inmate that requests for Department or

contract staff to attend the execution shall be denied.

1.1.3.1.4 Notify the inmate that requests for other inmates to

attend the execution shall be denied.

1.1.3.2 Direct the inmate to review and update as necessary the Notification
in Case of Accident, Serious lllness or Death and Disposition of
Property, Form 71 1-1 . The Warden shall direct the inmate to provide
any changes no later than 14 days prior to the execution. lf the
inmate provides no instruction, the property and accounts shall be
disposed in accordance with Dep artment Order #711, Notification of
lnmate Hospitalization or Death.

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1 .1 .3.3 Advise the ¡nmate that his/her body shall not be used for organ
donation.

1 .1.3.4 Summarize the options ava¡lable with the inmate for release and
disposition of their body after the autopsy is performed. The Warden
shall direct the inmate to review the previously completed Disposition
of Remains, Form 710-3, and update as necessary no later than 14
days prior to the execution. lf the inmate provides no information or
the ¡nformation ¡s insufficient or incorrect the deceased shall be
disposed in accordance with Depa rtment Order #711, Notification of
lnmate Hospitalization or Death.

1 .1 .3.5 Advise the inmate he may request a last meal by completing the Last
Meal Request, Form 71O-5, and returning it no later than 14 days
prior to the execution. Reasonable effort shall be made to
accommodate the request.

710.03 EXECUTION TEAM MEMBERS

1.1 The Division Director for Offender Operations shall

1 .1.1 Establish a training schedule and identify dates for periodic on-site practice by the
Housing Unit 9 Section Teams, to include 10 training scenarios within the 12
months preceding the scheduled execution.

1.1.2 Conduct a minimum of two training sessions with multiple scenarios 2 days prior to
the scheduled execution. The lV Team members shall participate in at least one
training session with multiple scenarios within one day prior to the scheduled
execution.

1.1.2.1 All training sessions shall be documented and be included as part of a

permanent record created by the ASPC-Florence Warden to be
subm¡tted to the Department's General Counsel for archive, post
execution.

1.1 .3 Ensure periodic testing of all of the equipment in Housing Unit 9 occurs, affirming
electrical, plumbing, heating and air conditioning units are in working order and the
gas chamber is maintained.

1.2 The Division Director for Offender Operations provides for the planning and overall direction of
all pre-execution, execution and post-execution activities. The Division Director coordinates the
activities of the Southern and Northern Regional Operations Directors (SROD and NROD) and
the ASPC-Eyman or ASPC-Perryville and ASPC-Florence Wardens who activate the following
teams and oversee their activities, specifically:

1.2.1 Command

1.2.',t.1 Consists of a minimum of three team members:

1.2.1.1.1 Commander.

1.2.1.1.2 Recorder.

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1.2.1.1 .3 Telephone operator.

1.2.1.1 .4 Others as necessary.

1.2.1.2 Team members are selected by the Division Director for Offender
Operations with the documented approval of the Director.

1.2.1.3 Its team leader is selected by the Division Director for Offender
Operations.

1.2.1.4 Primary function of Command is the overall coordination of execution

procedures.

1.2.2 Housing Unit 9 Section

1.2.2.1 Consists of a section leader and two teams:

1.2.2.1.1 Restra¡ntTeam.

1.2.2.1 .2 Special Operations Team.

1.2.2.2 Team leaders are selected by the Division Director for Offender
operations with the documented approval of the Director.

1.2.2.3 The section leader is the ASPC-Florence Warden.

1.2.2.4 Primary function of the section leader is the overall coordination of

activities of the Restraint Team and the Special Operations Team to
ensure compliance with conditions of confinement and application of
approved procedures.

1.2.3 Restraint Team

1.2.3.1 Consists of a minimum of seven team members, including one team

leader.

1.2.3.2 Restraint Team members and the team leader are selected by the
Division Director for Offender Operations with the documented
approval of the Director.

1.2.3.3 Primary function of the Restraint Team is to provide continuous

observation of the inmate on the day of the execution and apply
appropriate restraint procedures and inmate management prior to,
during and after the execution.

1.2.4 Special Operations Team

1.2.4.1 Consists of a minimum of five team members:

1.2.4.1.1 Team Leader

1.2.4.1 .2 Recorder

1-2.4.'l .3 Three additional team members.

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1.2.4.2 Its team members and team leader are selected by the Division
Director for Offender Operations with the documented approval of
the Director.

1.2.4.3 The Special Operations Team Leader shall designate functions of the
other team members, including the selection of a member to observe
the procedure and serve as the Recorder.

1.2.4.4 Primary function of the Special Operations Team is to implement the

protocols associated with the execution with its primary duty being
the administration of the chemicals, and additionally mixing the
chemicals under the direct supervision of the lV Team Leader.

1.2.5 lntravenous Team Members (lV Team)

1.2.5.1 The lV Team will consist of any two or more of the following:
physician(s), physician assistant(s), nurse(s), emergency medical
technician(s) (EMT's), paramedic(s), military corpsman or other
cert¡fied or licensed personnel including those trained in the United
States Military. All team members shall be currently certified or
licensed within the United States to place lV lines.

1.2.5.2 The lV Team members shall be selected by the Director. Selection of

any team member shall include a review of the proposed team
member's qualifications, training, experience, and/or any professional
license(s) and certification(s) they may hold. Licensing and criminal
history reviews shall be conducted, by the lnspector General's Office
prior to assigning or retaining any lV Team member and upon the
issuance of a Warrant of Execut¡on.

1.2.5.3 The Director shall designate the lV Team Leader. The Division
Director for Offender Operations shall ensure all team members
thoroughly understand all provisions contained herein as written and
by practice.

1.2.5.4 The lV Team shall be responsible for inserting either peripheral lV

catheters or a central femoral line as determined by the Director
acting upon the recommendation of the lV Team Leader. The lV
Team Leader shall ensure all lines are functioning properly throughout
the procedure, supervise the Special Operations team in the mixing of
the chemicals, preparing the syringes, and monitoring the inmate
(including the level of consciousness and establishing the time of
death). The lV Team Leader shall supervise the administration of the
chemicals. A central femoral venous line will not be used unless the
person placing the line is currently qualified by experience, tra¡ning,
cert¡fication or licensure within the United States to place a central
femoral line.

1.2.5.5 lV Team members shall only be required to participate in the training

sessions scheduled for one day prior to the actual execution.

1.2.5.6 Documentation of lV Team members' qualifications, including training

of the team members, shall be maintained by the Department
Director or his designee.

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1.2.6 Maintenance Response Team (MRT)

1.2.6.1 Consists of three team members and a team leader, and reports to
Command.

1.2.6.2 Team members are selected by the ASPC-Florence Warden.

1.2.6.3 Primary function of MRT is to test all Housing Unit 9 equipment

utilized to impose the sentence of death and to ensure electrical,
plumbing, heating and air conditioning units are in working order.

1.2.7 Critical lncident Response Team (CIRT)

1 .2.7.1 Consists of three team members and a team leader, and reports to
Command.

1.2.7.2 The leader is the Employee Relations Administrator or designee

1.2.7.3 Team members are CIRT responders and selected by the Employee
Relations Administrator.

1.2.7.4 Primary function of CIRT is to educate staff regarding possible

psychological responses and effective coping mechanisms to affected
staff at all levels in the Department prior to, during and after the
execution. CIRT shall provide ongoing follow up contact to staff .

1.2.8 Traffic Control Team

1.2.8.1 Consists of eight team members and a team leader, and reports to
Command.

1.2.8.2 Team members and the team leader are selected by the Division
Director for Offender Operations.

1.2.8.3 Primary function is to confer with state and local law enforcement
agencies, establish check points and parameters for traffic control
and formulate inter-agency emergency response strategies. The team
also coordinates the ingress/egress for Department and contract staff
and other persons whose attendance is necessary at ASPC-Eyman or
ASPC-Perryville and ASPC-Florence. The Team's focus is the period
of time start¡ng twenty-four hours prior to the execution and
concluding when normal activities resume after the execution.

1.2.9 Escort Team

1.2.9.1 Consists of eight team members and a team leader, and reports to
Command.

1.2.9.2 Team members and the team leader are selected by the Division
Director for Offender Operations.

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1.2.9.3 Primary function is to coordinate the movement of all pre-approved

witnesses on and off prison grounds and within its perimeter. One
Escort Team is assigned to escort and assist pre-approved official,
victim, media, and inmate witnesses. Escort team members always
remain with witnesses within the established perimeter.

1.2.1O Victim Services Team

1.2.10.1 Consists of two team members and reports to the Escort Team
leader.

1.2.1O.2 The team leader is the Victim Services Office Administrator

1.2.10.3 Primary function is to ensure victims of the crime that resulted in the
imposition of death are informed of the execution date and the¡r
opportunity to witness the execution. The team explains the
execution process. lf the victim is interested ¡n attending, the team
submits the victim's name{s) for consideration.

1.2.10.4 Day of the Execution - The team leader meets with the victim(s) in a
predetermined stag¡ng area and accompanies them throughout the
process, including a briefing by the Director. The Team provides
support and advocacy as appropriate.

1.2.10.5 lf the v¡ctim(s) is interested ¡n speaking with the media after the
execution, the victim(s) is escorted to the Press Room for brief media
availability.

1.2.10.6 Post-Execution - The team leader ensures the victim{s) receives

follow up phone calls and support.

1 .2.11 Population Assessment

1.2.11.1 Southern Region Operations Director

1.2.11.1.1 ls responsible for the coordination of monitoring and

evaluation of inmate act¡vity at ASPC-Eyman and
ASPC-Florence.

1 .2.11 .1 .2 Continuously monitors and assesses the ¡nmate

population for any activity related to the execution or
its impact on the prison's operation at ASPC-Eyman
and ASPC-Florence.

1.2.11.2 ASPC-PerryvilleWarden:

1.2.11.2.1 ls responsible for the coordination of monitoring and

evaluation of inmate activity at ASPC-Perryville.

1 .2.11 .2.2 Continuously monitors and assesses the inmate

population for any activity related to the execution or
its impact on the prison's operation.

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1 .3 Desiqnation of ADC Staff and Others Selected to Assist with the Execution

1 .3.1 The ASPC-Eyman or ASPC-Perryville and ASPC-Florence Wardens shall review the
current teams' rosters and recommend retention and replacement of staff and
alternates to the Division Director for Offender Operations.

1.3.2 The Division Director for Offender Operations shall evaluate the teams' composition
and the Wardens' recommendations and forward final recommendations to the
Director.

1.3.3 ln the selection and retent¡on of section leaders and Housing Unit 9 team members,
the Division Director for Offender Operations shall consider:

1 .3-3.1 No employee who was suspended or demoted in the past 1 2 months

shall be considered. Any staff currently under investigation is also
ineligible.

1.3.3.2 Special consideration may be given to staff with pertinent specialized

training and qualifications.

1.3.3.3 Staff with less than two years employment with the Department
shall not be considered.

1.3.3.4 No staff serving on any team shall be related to the inmate by blood
or marriage or have any other legal relationship with the inmate, their
family or the crime victim(s).

1.3.4 Staff participation in the execution process is strictly voluntary. No Department

employee is required to attend or participate in an execution. Any staff volunteers
may withdraw from performing their assigned duties specific to the execut¡on at
any time by advising their Team Leader, advising a Team Member or advising their
immediate chain of command. All staff part¡cipating in the execution shall be
required to sign a Notice of Execution lnvolvement, Form 710-8.

710.O4 COMMUTATION HEARING PROCEEDINGS

1.1 The Arizona Board of Executive Clemency (BOEC) shall advise the Department of its plans to
convene a Commutation Hearing and its date and time. Upon receipt of the notice, the ASPC-
Eyman or ASPC-Perryville Warden shall arrange for a location in which the Commutation
Hearing will be held.

1 .1.1 lf the BOEC Commutation Hearing is held at the prison, the Department shall:

1 .1.1 .1 Require those in attendance to adhere to dress code as outlined in

Department Order #91 1, lnmate Visitation.

1.1.1.2 Comply with the open meeting laws as it applies to Board of

Executive Clemency hearings pursuant to A.R.S. 5 38-431.08.

710.05 DESIGNATION OF WITNESSES BY DIRECTOR

1 .1 The Director or designee shall be present during the execution

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1.1 .1 The Director shall invite

1.1.1.1 The Arizona Attorney General. A.R.S. 5 13-758

1.1.1.2 Twelve or more reputable citizens, including up to five Arizona-

market media.

1.1.1.3 The five official media witnesses selected as representatives, from

media-print, television/cable, radio, and the local market where the
crime occurred. These official media witnesses shall also agree to
serve as pool reporters.

1 .1.1.4 Law Enforcement and prosecutors from the jurisdiction where the
crime occurred.

1.1.1.5 Any crime victims and survivors of the crime for which the sentence
of death will be imposed, once the Victim Services Team identifies
those persons and provides to the Director a list of victim witnesses
within 14 days prior to the scheduled execution.

1.1.1.6 ln the event that the inmate wishes to designate one or more of their
attorneys or other members of their legal team (not to exceed a
cumulative three persons) to witness the execution, then the inmate
shall identify these witnesses twenty-one days prior to the execution,
and these witnesses shall sign and timely submit an Official Witness
Agreement (Form 710-6), whereupon the Director shall invite these
witnesses to attend the execution in accordance with section
71O.1O, 1.2.1.1 of this Department Order.

1.1.2 Minors shall not be permitted to witness an execution. A.R.S. 5 13-758

1.1.3 All witnesses are subject to a records check. Selection to participate is contingent
upon security clearance and Witness Agreement to adhere to the provisions
stipulated in the Official Witness Agreement and Official Witness/Pool Reporters
Agreements, Forms 710-6 and71O-7. The Director shall retain full discretion as to
the selection of and any changes in the witnesses selected for each scheduled
execution.

710.06 STATE AND LOCAL LAW ENFORCEMENT BRIEFING; SITE CHECKS

1.1 The Division Director for Offender Operations shall ensure state and local law enforcement is
periodically briefed and adequately prepared for the execution.

1.2 All of the equipment necessary to the administration of the execution shall be available on site
and in good working order including:

1 .2.1 Transportation vehicles.

1.2.2 Communication devices with inter-operability capability and restricted frequencies.

1.2.3 Climate control.

1.2.4 Tool control.

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1.2.5 Safetyequipment.

1.2.6 Audio/visualequipment.

1.2.7 Utilityinfrastructure.

1.2.8 Keycontrol/locking devices.

1.2.9 Medical emergency response capability.

1.3 The Division Director for Offender Operations shall take all necessary steps to timely rectify
def iciencies.

710.O7 THIRTY-FIVE DAYS PRIOR TO THE DAY OF EXECUTION - COMPLEX

1.1 The Warden or designee of ASPC-Eyman or ASPC-Perryville shall confirm in writing the
following steps were completed:

1 .1.1 Read the Warrant to the inmate.

1.1.2 Outline for the inmate how conditions of confinement will be modified over the next
thirty-five days and briefly describe the relevant aspects of the execution process.

1.1 .3 Off er the inmate the opportunity to contact their Attorney of Record by phone and
to speak with a facility chaplain.

1 .1.4 Obtain the inmate's current weight and provide that information to the Division
Director for Offender Operations and the Housing Unit 9 Section Leader.

1.1.5 Transfer the inmate to the single-person cell on Death Row Browning or the Lumley
Unit that has been retrofitted expressly for the purpose of holding the inmate.

1.1.5.1 Before transferring the inmate into the cell, the inniate shall be strip
searched, screened on the BOSS chair and then issued a new set of
clothes and shoes to wear.

1.1.5.2 The single-person cell shall be thoroughly searched prior to placing

the inmate in the cell.

1 .1.6 Place the inmate on 24-hour Continuous Observation and post staff to the inmate's
cell on an on-going basis to maintain visual contact with the inmate until such time
as the inmate is transferred to Housing Unit 9 at ASPC-Florence.

1 .1 .7 Establ¡sh an Observation Record to chronicle staff 's observations of the inmate's

activities and behavior until the sentence of death is imposed.

1.2 Conditions of Confinement - The ASPC-Eyman or ASPC-Perryville Warden shall

1.2.1 Ensure none of the inmate's personal property is transferred with the inmate,
except as provided in this section.

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1.2.2 Have the inmate's personal property inventoried in their presence before the
transfer of cells occurs and then have it boxed, sealed and removed from the cell.
Store the inmate's property pending receipt of written instruction by the inmate
regarding disposition of property or otherwise dispose of the property as outlined in
sect¡on 710.O2 of this Department Order.

1.2.3 Ensure all remaining property possessed by the inmate in the cell comply with
indigent status items; any exceptions must be pre-approved in writing by the
Division Director for Offender Operations.

1.2.4 Allow the inmate to keep in the cell one box each of legal and religious materials, a
pencil and paper, and a book or periodical.

1.2.5 lssue the inmate a new mattress, pillow and bedding

1.2.6 Provide the inmate limited hygiene supplies, including a towel and washcloth, and
exchange these items on a daily basis.

1.2.7 lssue the inmate a clean set of clothing and bedding daily

1.2.8 Ensure all inmate medications are unit-dosed and, when available issued in liquid
form, and none of the inmate's medication including over-the-counter medications
be dispensed or maintained by the inmate as Keep-on-Person.

1.2.9 Ensure the inmate has access to a department television set that is secured outside
of the cell, and does not have access to any other appliances.

1.2.10 Continue to provide outdoor exercise and showers, non-contact visits and phone
calls per the current schedule for other death row inmates in Browning or the
Lumley Unit.

710.08 THIRTY-FIVE DAYS PRIOR TO THE DAY OF EXECUTION - CENTRAL OFFICE

1.1 The Division Director for Offender Operations:

1.1.1 ldentifies and assigns team leaders and members, with documented approval by the
Director, and upon approval shall activate the teams.

1.1.2 Confirms preventive maintenance in Housing Unit 9 occurs and that an equipment
inventory is completed, and appropriate and timely action is taken.

1.1.3 Directs the initiation of the Continuous Observation Log commencing on the 35th
day prior to the day of the execution. The log shall follow the inmate from ASPC-
Eyman or ASPC-Perryville to Housing Unit 9 at ASPC-Florence and be maintained
until the execution occurs or a stay of execution is issued.

1.1.4 Activates the tra¡ning schedule ensuring staff participating in the execution receives
adequate training, written instruction and practice, all of which is documented.

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1 .2 The Assistant Director for Health Services Contract Monitoring Bureau

1.2.1 Directs ADC's Health Services staff or ADC's contracted Health Services provider
to conduct a medical records file review to identify any prescribed medication(s)
and dosages the inmate is currently or was recently taking. ADC's Health Services
staff or ADC's contracted Health Services provider shall modify prescribed
medications as may be necessary.

1.2.2 Directs ADC's Health Services staff or ADC's contracted Health Services provider
to dispense all inmate medications in unit doses and, when available in liquid form.
No medication including over-the-counter medications shall be provided or
maintained by the inmate as Keep-on-Person.

1.2.3 Ensures ADC's Health Services staff or ADC's contracted Health Services provider
continuously monitors for significant changes in the inmate's medical or mental
health and reports findings immediately to the Department's General Counsel.

1.3 The Media Relations Office

1 .3.1 lssues a news advisory announcing the date of the execution

1.3.2 Facilitates up to one non-contact interview with the inmate by phone, per day, with
media from the day the Warrant is issued until the day before the sentence of death
is imposed excluding weekends and state and federal holidays. The inmate and
Attorney of Record may select among these requests that are submitted to the
Media Relations Office and recommend the order in which they occur. The inmate
may refuse any or all media requests for interviews.

1 .4 The Office of Victim Services - ldentifies and advises victims of the crime for which the inmate
has been sentenced to death of the issuance of the Warrant of Execution and the scheduled
date and time of the execution.

710.09 TWENTY-ONE DAYS PRIOR TO THE DAY OF EXECUTION - CENTRAL OFFICE

1.1 The Media Relations Office

1.1.1 Forwards media-witness applications to the lnspector General for background

investigation. The lnspector General shall advise the Director of any issues arising
from such investigations.

1.1.2 Sends media-witness agreement forms (Official Witness Agreement, Form 710-6
and as applicable, Official Witness/Pool Reporter Agreement, Form 710-7) to
identified media-witnesses, and establishes a deadline for the return of all such
forms.

1.1.3 All witnesses shall sign and timely submit an Official Witness Agreement, Form
710-6, prior to being cleared and added to the witness list.

1.1.3.1 All official witnesses who are also members of media/press and are
selected to serve as pool reporters shall also sign and t¡mely return the
Official Witness/Pool Reporter Agreement, Form 7"lO-7.

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710.10 FOURTEEN DAYS PRIOR TO THE DAY OF EXECUTION _ CENTRAL OFFICE

1.1 The lnspector General or designee:

1.1.1 Finalizes arrangements with a Medical Examiner Office for the disposition of the
body, security for the Medical Examiner's vehicle and the custodial transfer of the
body.

1.1.2 Obtain a body bag and tag from the Medical Examiner's Off ice.

1.2 General Counsel

1.2.1 Finalizes a list of all witnesses including official, victim, inmate witnesses and
media/pool reporters, through coordination with the Offices of Victim Services and
Media Relations, for the Director's review and documented approval.

1.2.1.1 Upon documented approval the Director or designee shall prepare a

written invitation to each chosen witness. (see Attachment A)

1.3 The Media Relations Office - lssue a news adviso ry announcing the date and time of the
execution.

710.11 TWO DAYS PRIOR TO THE DAY OF EXECUT¡ON

1.1 The Diviqion Director for Offender Operations:

1.1.1 Schedules and conducts on-site scenario training sessions, modifying practices as
warranted.

1."r.2 Confirms adequate staffing and vehicles are in place for regular operations and the
execution.

1.2 The ASPC-Florence Warden

1.2.1 Confirms staff assigned to the Maintenance Response Team (MRT) is scheduled
and will be on-site eight hours prior to the time scheduled for the imposition of
sentence.

1.2.2 Restricts access to Hous¡ng Unit 9 to those with expressly assigned duties.

1.2.3 Readies Housing Unit 9 for the transfer of the inmate.

1.2.4 Verifies execution inventory, including the chemicals to be used, and equipment
checks are completed and open issues resolved.

710.12 TWENTY-FOUR HOURS PRIOR TO THE DAY OF EXECUTION

1.1 On-site scenario exercises continue.

1.2 Final preparation of Housing Unit 9 is completed. Each room rèceives final evaluation specific
to its functions including security, climate control, lighting, sound, sanitation, and that
separation screens and appropriate restraints are at the ready.

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1.3 Detailed staff briefings are prov¡ded.

1.4 The ASPC-Eyman or ASPC-Perryville Warden shall ensure the inmate receives the last meal by
1900 hours. Every reasonable effort to accommodate the last meal request will have been
made. All eating utensils and remaining food and beverage shall be removed upon completion
of the meal.

1.5 The ASPC-Eyman or ASPC-Perryville Warden shall ensure non-contact visits and phone calls
are concluded by 21OO hours.

1.5.1 The inmate's telephone privileges shall be terminated at 21 00 hours the day prior to
the execution, excluding calls from the inmate's Attorney of Record and others as
approved by the Division Director for Offender Operations.

1.5.2 The inmate's visitation privileges shall be terminated at 2100 hours the day prior to
the execution. The inmate will be permitted two hours of in-person visitation with
no more than two Attorneys of Record, concluding one hour prior to the scheduled
execution.

1.6 The inmate is prepared for transfer to Housing Unit 9 by the prescribed means

710.13 TWELVE HOURS PRIOR TO AND THROUGH THE EXECUTION

1 .1 Restricting Access to lnstitution Property - During the final twelve hours prior to the execution,
access to ASPC-Eyman or ASPC-Perryville and ASPC-Florence is limited to:

1 .1 .1 On-duty personnel.

1.1.2 On-duty contract workers.

1.1.3 Volunteers deemed necessary by the Wardens.

1 .1.4 Approved delivery vehicles.

1 .1 .5 Law enforcement personnel on business-related matters.

1 .1 .6 Restrictions to these facilities shall remain in effect until normal operations resume
after the execution or a stay of execution is issued.

1.2 Transfer of the inmate from Browning or Lumley Unit to Housing Unit 9

1.2.1 The inmate shall be secured and transferred by the Execution Restraint Team per
the prescribed means the night before the execution.

1.2.2 Housing Unit 9 staff shall take custody of the inmate and the Observation Log.
Staff shall assume maintenance of the log until the execution is completed or a stay
of execution is issued.

1.2.3 Upon the inmate's arrival, the inmate may be offered a mild sedative

1.2.4 No later than five hours prior to the execution, the inmate shall be offered a light
meal. All eating utensils and remaining food shall be removed upon completion of
the meal.

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1.2.5 No later than four hours prior to the execution, the inmate may be offered a mild
sedative.

1.2.6 These time frames may be adjusted as necessary in the event of a stay of
execution or other exigencies.

1.3 Housinq Unit 9 Conditions of Confinement

1 .3.1 The inmate shall remain on Continuous Watch. Staff shall record observations and
make entries in the Observation Record during the final four hours in hours, and
minutes.

1.3.2 The inmate shall be issued one pair each of pants, boxer shorts and socks, and a
shirt on the morning of the execution.

1.3.3 The cell shall be furnished with a mattress, pillow and pillowcase, one each top and
bottom sheet, a blanket, a washcloth and towel, and toilet paper.

1.3.4 The inmate may have a pencil and paper, religious items, a book or periodical and
indigent-sized hygiene supplies (liquid soap, toothpaste) and a toothbrush and
comb. These items may be made available only for the duration of the use and shall
be removed immediately thereafter. Any other requested property shall require
approval by the Division Director for Offender Operations, and shall be documented.

1.4 Population Management - ASPC-Eyman or ASPC-Perryville and ASPC-Florence shall go on

lockdown status from between two to six hours prior to the time the execution is scheduled to
occur at the direction of Command. They shall remain on lock down throughout the execution.
After the conclusion of the execution, the prisons shall return to regular operations at the
direction of Command.

1.5 Additional Oper ations Reouirements

1.5.1 Witness Escort Teams shall process, transport and remain with pre-approved official
witnesses, inmate witnesses, media witnesses and victim(s) witnesses through the
conclusion of the execution and their return to designated staging areas per
prescribed means.

1.5.1.1 Teams shall ensure each witness group is separated from the other
witness groups at all times.

1.5.1 .2 The Director or designee shall provide a brief overview of the

execution for the official witnesses. ïhe Director shall advise
witnesses that the curtains in the execution chamber may be drawn
prior to the conclusion of the execution in the event of a legitimate
penological objective which would merit such closure and then
reopened when the execution resumes, and that an lV Team member
will enter into the chamber and physically manipulate the ¡nmate to
check consciousness.

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1 .5.1 .3 ln the event the inmate has designated one of his attorneys to
witness the execution, temporary office space will be provided for
the inmate's counsel in the Administration Building during the
scheduled day of execution. One attorney and two additional
members of the legal team may be permitted to remain in the office
space during the execution. The inmate's legal team will be perm¡tted
to bring into the temporary office space one mobile phone, one
tablet, and one laptop. While the attorney witness is in the witness
room, a member of the Witness Escort Team shall hold one mobile
phone designated by the attorney, to be made available to the
attorney in exigent circumstances. The mobile phone may not be
used inside the witness room.

1.5.2 Upon the direction of the Director to proceed:

1.5.2.1 The APSC-Florence Warden shalldirect the Execution Restraint Team

to prepare the inmate for escort into the execution chamber.

1.5.2.2 Prior to moving the inmate from the holding cell to the execution
table, the Director shall confer with the Attorney General or designee
and the Governor or designee to confirm there is no legal impediment
to proceeding with the lawful execution.

1.5.2.3 when the inmate is secured on the execution table by the team and
readied by qualified medical personnel, the Warden shall advise the
Director.

1.5.2.4 The Director shall reconfirm with the Attorney General or designee
and the Governor or designee that there is no legal impediment to
proceeding. Upon oral confirmation that there is no legal impediment
to proceeding with the execution, the Director may order the Warden
to proceed with the execution.

1.5.2.4.1 lf there is a legal impediment the Director shall

instruct the ASPC-Florence Warden to stop, and to
notify the inmate and witnesses that the execution
has been stayed or delayed. The Warden shall also
notify command to notify the Media Relations staff
who shall advise the media in the Press Room.

1.5.2.5 The Warden shall read aloud a summary of the Warrant of

Execution. The Warden shall ask the inmate if he wishes to make a
last statement. The microphone will remain on during the last
statement. lt will be turned off in the event the inmate uses
vulgarity or makes intentionally offensive statements.

"t.5.2.6 The Director shall instruct the disbursement of chemicals to begin

by the prescribed means,

f .5.3 Pronouncement and Documentation of Death

1 .5.3.1 The Director shall announce death when it has occurred

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1.5.3.2 The ASPC-Florence Warden shall complete and sign the return of
the Death Warrant pursuant to A.R.S. 5 13-759. The Director shall
file the document with the sentencing court and the Arizona
Supreme Court within 48 hours.

1.5.3.3 A Medical Examiner shall take custody of the body and issue a
Certificate of Death.

1.6 Stay of Execution - Upon receipt of notification that the court has issued a Stay of Execution,
the Director shall consult with the Attorney General's Office and advise Command.

1.6.1 Upon receipt of notif¡cation, the Housing Unit 9 Section Leader shall:

1.6.1.1 Advise the witnesses a Stay of Execution has been issued.

1.6.1.2 Following consultation with the Director, direct that the catheters
be removed, if applicable, and direct the Restraint Team to return
the inmate to the holding cell.

1.6.1.3 lnstruct the Special Operations to stand down.

1.6.2 Command shall inform the following teams of the Stay of Execution:

1.6.2.1 Traffic Control Team Leader.

1.6.2.2 Population Assessment.

1.6.2.3 Critical lncident Response Team Leader.

1.6.2.4 Media Relations Director.

1.6.2.5 Victim Services Team Leader.

1.6.2.6 Escort Team leader.

1.6.3 The Traffic Control Team Leader shall not¡fy protestors of the issuance of the Stay
of Executíon.

1.6.4 The Escort Team shall commence escorting witness groups from Housing Unit 9 as
set forth herein.

1.6.5 Upon Command's instruction, the inmate shall be transported from Housing Unit 9
back to Death Row at Browning or Lumley Unit and their personal possessions
returned. Following the transport, the inmate will be permitted to consult with the
inmate's attorney(s) upon request.

710.14 POST-EXECUTION

1.1 Removinq Witnesses from Housinq Unit 9

1 .1.1 After the pronouncement of death, witnesses shall be escorted in the prescribed
order from the facility.

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1.1.1.1 Each group of witnesses will continue to be kept separated from the
other groups at all times.

1.1.1.2 Official witnesses who are media pool reporters will return to the
Press Room to participate in the media briefing.

1.1.1.3 Victim witnesses speaking with the media will be escorted to the
Press Room.

1.1 .2 Media may remain on site in a designated location outside the secure perimeter for
a limited time to complete live broadcasts.

1.2 Site Clean Up

1.2.1 Under the supervision of a person designated by the ASPC-Florence Warden,

Housing Unit 9 shall be cleaned and secured.

1 .2.2 lnstitutional staff trained in infectious diseases preventive practices will utilize
appropriate precautions in cleaning Housing Unit 9.

1.3 Normal Operations

1.3.1 Command shall determine when the prisons resume normal operations after
receiving assessments from the Wardens of ASPC-Florence and ASPC-Eyman or
ASPC-Perryville.

1.3.2 Department personnel shall be deactivated at the direction of Command

1 .4 Execution Documentation

1.4.1 The ASPC-Florence Warden shall be responsible to gather all documents perta¡ning
to the execut¡on and forward to the Department's General Counsel for archive.

1.4.2 PursuanttoA.R.S. g 13-759(B),theDirectorshallsendwrittennotif¡cationtothe

sentencing court and the Arizona Supreme Court stating the time, mode and
manner in which the Warrant was carried out. (see Attachments B and C)

710.15 PROCEDURES FOR NEWS MEDIA

1.1 Reasonable efforts will be made to accommodate representatives of the news media before,
during and after a scheduled execution however; the Department reserves the right to regulate
media access to ensure the orderly and safe operations of its prisons.

1.2 The Media Relations Office shall coordinate the release of information to news media outlets.
All Department and contract staff are expressly prohibited from providing information not
readily available in the public domain.

1.3 Update Prior to the Execution - Followin g activat¡on of the Press Room, the Media Relations
Director and the Public lnformation Officer shall provide the news media with regular briefings
or updates.

1 .4 Media Orientation and Releases - The Media Relations Director shall provide general information
regarding the execution and about the inmate

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1 .4.1 Media Representatives will be informed how the press pool will be establ¡shed and
advised that if they are selected as press pool witnesses, they shall be required to
complete and sign Media Witness Press Pool Agreement, Form 71O-7, ín addition
the Official Witness Agreement, Form 710-6, prior to the execution.

1.4.2 Media Representatives will return to the Press Room after the execution to answer
questions of all other media representatives concerning their observations during
the execution, prior to filing or reporting their story.

1.5 Press Room Operations

1 .5.1 Media representatives requesting to witness an execution must submit written

requests to the Media Relations Office no later than 28 days prior to the execution.
Each request must include the name, social security number and birth date of media
requesting access. Only those news organizations that have submitted written
requests within the stated time frame shall be considered.

1.5.2 The Media Relations Office shall finalize recommendations for selected media to
perform official witness/pool reporter functions 14 days prior to the execution.

1 .6 Briefino and Updates

1.6.1 The Media Relations Office shall provide press briefing packets for reporters.

1.6.2 A brief summary of inmate's activities during the finaltwenty-four hours, activities
related to the execution and sequence of events, may be provided.

1.7 News Media Selection

1 .7.1 No more than five members of the Arizona media may be selected to witness the
execution as official witnesses. Selected media will perform the additional duties of
pool reporter:

1 .7.1 .1 Print.

1 .7.1.2 Radio

"l.7.1.3 Television/Cable.

1 .7.1.4 Local media representative in the market where the crime was
committed,

1.7.2 Media is held to the same standards for conduct as are all other official witnesses

1.7.3 Command may exclude any media witness at any time if the media witness fails to
abide by the provisions of the Official Witness and Pool Reporter Agreements
(Forms 710-6 and 710-71.

1.7.4 Media witnesses are not permitted to bring unauthorized items into Housing Unit 9.
Unauthorized items include:

1.7.4.1 Electronic or mechanical recording devices

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1.7.4.2 Still, moving picture or video tape camera.

1 .7.4.3 Tape recorders or similar devices.

1.7.4.4 Radio/televisionbroadcastingdevices.

1 .7.5 Each pool reporter shall be provided a tablet of paper and a pencil to take notes
from the time they complete security screening and board the bus until they are
returned to the Press Room after the conclusion of the execution.

1.7.6 Official witnesses who are pool reporters shall attend a pre-execution briefing.

IMPLEMENTATION
The ASPC-Florence and ASPC-Perryville Wardens shall maintain Post Order #015, Death Watch Security Officer,
delineating post-specific responsibilities. The ASPC-Florence Warden shall also maintain Post Order #015-401,
Housing Unit-9 Security Watch.

{Original Signature on File}

Charles L. Ryan
Director

ATTACHMENTS
Attachment A - Letter of lnvitation to Witness an Execution
Attachment B - Return of Warrant Notification - Supreme Court
Attachment C - Return of Warrant Notification - Superior Court
Attachment D - Preparation and Administration of Chemicals

FORMS LIST
71O-1, Method of Execution
7 1O-2, lnmate Witness lnformation
71O-3, Disposition of Remains
71O-4, Authorized Witnesses for Execution Log (4, B and C)
71O-5, Last Meal Request
710-6, Official Witness Agreement
71O-7, Official Witness/Pool Reporter Agreement
71O-8, Notice of Execution lnvolvement

CROSS.REFERENCE INDEX
Department Order #2O1, þSal Services - lnformation Release
Depa rtment Order #2O7, Media Relations
Department Order #711, Notification of lnmate Hospitalization or Death
Department Order #91 1, lnmate Visitation

AUTHORITY
A.R.S. g 13-757 (B), Methods of lnfliction of Sentence of Death

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A.R.S. g 13-757 (C), ldentity of Executioners

A.R.S. ! l3-758, Persons Present at Execution of Sentence of Death; Limitations
A.R.S. E 13-759 (B), Return Upon Death Warrant
A.R.S. E 13-4021 through 13-4026,lnsanity or Pregnancy of Persons under Death Sentence
Arizona Rules of Criminal Procedure, Rule 31.17(c)(3), Date and Time of Execution; Notification to Supreme
Court
A.R.S. g 1-215 (28), Definitions
A.R.S. 5 13-105 (30), Definitions

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ATTACHMENT A
DEPARTMENT ORDER 710

SAMPLE
LETTER OF INVITATION TO WITNESS AN EXECUTION

Date

Name
Mailing address
Mailing address

Dear

Thank you for expressing interesting in serving as a witness.

Please be advised that you are selected to witness the execution of

lnamel lnumberl, on ldatel at [timel subject to the conditions stipulated
in this correspondence.

There are three kinds of witnesses. They are 1) Off icial Witnesses including Official Witnesses who are
members of the media and will serve as Pool Reporters,2l the lnmate's Witnesses and 3) the Victim(s)
Witnesses.

All witnesses are required to complete the Witness Agreemenf form and return it to the Media Relations
Office of the Arizona Department of Corrections no later than ldatel by fax, mail, hand delivery
or as an e-mail attachment.

Official Witnesses who are members of the media and will be serving as Pool Reporters are also required to
complete the Official Witnesses/Pool Reporters Agreement form. This form must be returned as well to the
Media Relations Office of the Arizona Department of Corrections no later than the Friday before the
scheduled date of the execution, ldatel by the same means

Failure to fully complete and return on time the required forms with receipt by the Department before 5 P.M.
on ldatel, will result in your removal from the list of approved witnesses

For additional information and to confirm receipt of your materials, you are welcome to contact the Media
Relations Off ice by phone at 602-542-31 33, by fax at 602-542-2859 or e-mail at media@azcorrections.gov.

Sincerely,

Media Relation Director

Applicable Attachments:
_Witness Agreement'lorm
Official Witnesses/Pool Reporters Agreement lorm

JANUARY 11. 2017

133
ATTACHMENT B
DEPARTMENT ORDER 710

SAMPLE
RETURN OF WARRANT NOTIFICATION

Supreme Court

DATE:

The Honorable
Chief Justice of the Supreme Court of Arizona
4O2 Arizona State Courts Building
1501 West Washington Street
Phoenix, Arizona 85007-3329

RE Return of Warrant of Execution

State vs.

Supreme Court Number:

County Number:

Chief Justice

This is to advise you that in accordance with the Warrant of Execution, Supreme Court Number, and pursuant to
A.R.S. 5 13-759(B), the imposition of the sentence of death of was carried out
at the Arizona State Prison Complex-Florence on 20 ,at A.M./P.M.

The mode and manner of the death was by lethal

Sincerely,

Charles L. Ryan
Director
Arizona Department of Corrections

JANUARY 11, 2017

134
ATTACHMENT C
DEPARTMENT ORDER 71O

SAMPLE
RETURN OF WARRANT NOTIFICATION

Superior Court

DATE:

The Honorable
Presiding Judge
Superior Court of Arizona
ln County
Arizona

RE: Return of Warrant of Execution

State vs.

Supreme Court Number:

County Number:

Judge

This is to advise you that in accordance with the Warrant of Execution, Supreme Court Number, and pursuant to
A.R.S. 5 1 3-759(B), the imposition of the sentence of death of was carried out
at the Arizona State Prison Complex-Fforence on 20 _,at _ A.M./P.M

The mode and manner of the death was by lethal

Sincerely,

Charles L. Ryan
Director
Arizona Department of Corrections

JANUARY 11,2017

135
ATTACHMENT D
DEPARTMENT ORDER 710
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PREPARATION AND ADMINISTRATION OF CHEMICALS

A. Obtaining Chemicals and Equipment

1 . Upon receipt of the Warrant of Execution, the Housing Unit 9 Section Leader shall:

l. Confirm the equipment for the procedure and ensure all equipment necessary to properly
conduct the procedure is on site, immediately available for use and functioning properly.

ll. Ensure all medical equipment, including an ultrasound machine and a backup
electrocardiograph is on site, immediately available for use and functioning properly.

lll. Ensure that complete sets of chemicals are on site, not expired, and immediately available for
use.

IV Ensure the chemicals are ordered, arrive as scheduled and are properly stored. The chemicals
shall be stored in a secured, locked area that is temperature regulated and monitored to
ensure compliance with manufacturer specifications, under the direct control of the Housing
Unit 9 Section Leader.

B. Preparation of Chemicals

1 Prior to the preparation of the chemicals, the Director or designee shall verify the chemicals to be
used, the quantity and the expiration date.

2 At the appropriate time, the Housing Unit 9 Section Leader shall transfer custody of the chemicals to
the Special Operations Team to begin the chemical(s) and syringe preparation in the chemical room,
under the direct supervision by the lV Team Leader.

3 The Special Operations Team Leader will assign a team member(s) to assist preparing each chemical
and the corresponding syringe. The lV Team Leader will supervise the process. The lV Team Leader,
with the assistance of the Special Operations Team members, shall prepare the designated
chemical(s) and syringes as follows:

a One-drug protocol - One full set of syringes is used in the implementation of the death
sentence (Bank "A") and an additional complete set of the necessary chemicals shall be
obtained and kept available in the chemical room, but need not be drawn into syringes unless
the primary dosages prove to be insufficient for successful completion of the execution.

¡ Three-drug protocol - One full set of syringes is used in the implementation of the death
sentence (Bank "4") and an additional complete set of the necessary chemicals shall be
drawn into syringes and kept refrigerated in the chemical room, in the event the backup
dosages (Bank "8") are necessary for successful completion of the execution.

4. The lV Team Leader, with the assistance of a Special Operations Team member, shallbe responsible
for preparing and labeling the assigned sterile syringes in a distinctive manner identifying the specific
chemical contained in each syringe by i) assigned number, ii) chemical name, iii) chemical amount
and iv) the designated color, as set forth in the chemical charts below. This information shall be
preprinted on a label, with one label affixed to each syringe to ensure the label remains visible.

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C. Chemical Charts; Choice of Protocol

1 Charts for all chemical protocols follow. The Director shall have the sole discretion as to which drug
protocol will be used for the scheduled execution. This decision will be provided to the inmate and
their counsel of record in writing at the time the state files a request for Warrant of Execution in the
Arizona Supreme Court. lf the inmate's counsel or other third parties acting on behalf of the
inmate's counsel are able to obtain from a cert¡fied or licensed pharmacist, pharmacy, compound
pharmacy, manufacturer, or supplier and provide to the Department the chemical pentobarbital in
sufficient quantity and quality to successfully implement the one-drug protocol with pentobarbital set
forth in Chart A, then the Director shall use the one-drug protocol with pentobarbital set forth in
Chart A as the drug protocol for execution. lf the inmate's counsel or other third parties acting on
behalf of the inmate's counsel are unable to obtain such pentobarbital, but are able to obtain from a
certified or licensed pharmacist, pharmacy, compound pharmacy, manufacturer, or supplier and
provide to the Department the chemical sodium pentothal in sufficient quantity and quality to
successfully implement the one-drug protocol with sodium pentothal set forth in Chart B or the
three-drug protocol with sodium pentothal set forth in Chart C, then the Director shall have the sole
discretion as to wh¡ch drug protocol (Chart B or Chart C) will be used for the scheduled execution.

2 A qualitative analysis of any compounded or non-compounded chemicalto be used in the execution

shall be provided upon request within ten calendar days after the state seeks a Warrant of
Execution. The decision to use a compounded or non-compounded chemical will be provided to the
inmate and their counsel of record in writing at the time the state files a request for Warrant of
Execution in the Arizona Supreme Court.

CHART A: ONE-DRUG PROTOCOL WITH PENTOBARBITAL

Syringe No Label
20mL Sterile Saline Solution, BLACK
2.59m Pentobarbital,

t
GREEN
2.59m Pentobarbital, GREEN
2OmL Sterile Saline Solution, BLACK

a Syringes 24, and 34, will have a dose of 2.5 grams (gm) of Pentobarbital for a total of 5
grams. Each syringe containing Pentobarbital shall have a GREEN label which contains the
name of chemical, chemical amount and the designated syringe number.

a Syringes 14, and 44, each contain 20 milliliters (mL) of a sterile saline solution, and shall have
a BLACK label which contains the name of the chemical, chemical amount and the designated
syringe number.

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CHART B: ONE-DRUG PROTOCOL WITH SODIUM PENTOTHAL

Syringe No. Label

2OmL Sterile Saline Solution, BLACK
1.259m Sodium Pentothal, GREEN
1.259m Sodium Pentothal, GREEN
H 1.259m Sodium Pentothal, GREEN

il 1.259m Sodium Pentothal, GREEN

20mL Sterile Saline Solution, BLACK

a Syringes 2A, 3A,44, 54, each contain 1.259m/50ml of Sodium Pentothal / 1 in 50mL of
sterile water in four 60mL syringes for a total dose of 5 grams of Sodium Pentothal. Each
syringe containing Sodium Pentothal shall have a GREEN label which contains the name of
chemical, chemical amount and the designated syringe number.

a Syringes 14, and 64, each contain 20mL of a sterile saline solution, and shall have a BLACK
label which contains the name of the chemical, chemical amount and the designated syringe
number.

CHART C: THREE-DRUG PROTOCOL WITH SODIUM PENTOTHAL. VECURON¡UM BROMIDE/OR

ROCURONIUM BROMIDE/OR PANCURONIUM BROMIDE AND POTASSIUM CHLORIDE

Syringe No. Label

20mL Sterile Saline Solution, BLACK
1.259m Sodium Pentothal, GREEN
1.259m Sodium Pentothal, GREEN
ffi 1.259m Sodium Pentothal, GREEN
1.259m Sodium Pentothal, GREEN

t 20mL Sterile Saline Solution, BLACK

SOmg Vecuronium Bromide/or Rocuronium
Bromide/or Pancuronium Bromide, BLUE
til SOmg Vecuronium Bromide/or Rocuronium
Bromide/or Pancuronium Bromide, BLUE
2OmL Sterile Saline Solution, BLACK
12OmEq Potassium Chloride, RED
12OmEq Potassium Chloride, RED
H 2OmL Sterile Saline Solution, BLACK

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a Syringes 2A,3A,44, and 54, each contain 1.259m/50ml of Sodium Pentothal/ 1 in SOmL of
sterile water in four 60mL syringes for a total dose of 5 grams of Sodium Pentothal in each set.
Each syringe contain¡ng Sodium Pentothal shall have a GREEN label which contains the name of
chemical, chemical amount and the designated syringe number.

Syringes 14, 6A, 94, and 124, each contain 20mL of a sterile saline solution, and shall have a
BLACK label which contains the name of the chemical, chemical amount and the designated
syringe number.

Syringes 74, and 84, each contain 50mg of Vecuronium Bromide/or Rocuronium Bromide/or
Pancuronium Bromide for a total of lOOmg. Each syringe containing Vecuronium Bromide/or
Rocuronium Bromide/or Pancuronium Bromide shall have a BLUE label which contains the name
of the chemical, chemical amount and the designated syringe number.

a Syringes 10A, and 11A, each contain 120mEq of Potassium Chloride for a total of 240mEq of
Potassium Chloride per set. Each syringe containing Potassium Chloride shall have a RED label
which contains the name of the chemical, chemical amount and the designated syringe number.

3. After the lV Team prepares all required syringes with the proper chemicals and labels as provided in
the Chemical Chart, the Special Operations Team, under the supervision of the lV Team, shall attach
one complete set of the prepared and labeled syringes to the 2-Gang, 2-Way Manifold in the order in
which the chemical(s) are to be administered. The syringes will be attached to the 2-Gang, 2-Way
Manifold in a manner to ensure there is no crowding, with each syringe resting in its corresponding
place in the shadow board which is labeled with the name of the chemical, color, chemical amount
and the designated syringe number.

4. The syringes shall be affixed in such a manner to ensure the syringe labels are clearly visible. Prior to
attach¡ng the syringes to the 2-Gang, 2-WaV Manifold, the flow of each gauge on the manifold shall
be checked by the lV Team Leader running the sterile saline solution through the line to confirm
there is no obstruction.

5 After all syringes are prepared and affixed to the 2-Gang, 2-Way Manifold in proper order, the
Special Operations Team Leader shall confirm that all syringes are properly labeled and attached to
the manifold in the order in which the chemicals are to be administered as designated by the
Chemical Chart. Each chemical shall be administered in the predetermined order in which the
syringes are affixed to the manifold.

6 The quantities and types of chemicals prepared and administered may not be changed in any manner
without prior documented approval of the Director. The Director's discretion with regard to the
quantities and typos of chemicals is limited to what is expressly set forth in this Department Order.
lf, after a Warrant of Execution has been issued, the Director determines that it is necessary to
change the quantities or types of chemicals to be used in the impending execution, then the Director
shall immediately notify the inmate and the inmate's counsel in writing.

7 All prepared chemicals shall be utilized or properly disposed of in a timely manner after the time
designated for the execution to occur.

I The chemical amounts as set forth in the Chemical Chart are designated for the execution of persons
weighing 5OO pounds or less. The chemical amounts will be reviewed and may be revised as
necessary for an inmate exceeding this body weight.

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I The Special Operations Team Recorder is responsible for completing the Correctional Service Log,
Form 105-6. The Recorder shall document on the form the amount of each chemical administered
and confirm that it was administered in the order set forth in the Chemical Chart. Any deviation from
the written procedure shall be noted and explained on the form.

D. Movement and Monitoring of lnmate

1 Prior to moving the inmate from the holding cell to the execution table, the Director will confer with
the Attorney General or designee and the Governor or designee to confirm there is no legal
impediment to proceeding with the lawful execution and there are no motions pending before a court
which may stay further proceedings.

2 The inmate may be offered a mild sedative based on the inmate's need. The sedative shall be
provided to the inmate no later than four hours prior to the execution, unless it is determined
medically necessary. The offer of the mild sedative, the inmate's decision, and the administration of
the sedative, if chosen, shall be documented in the watch log.

3 At the designated t¡me, the overhead microphone will be turned on and the ¡nmate will be brought
into the execution room and secured on the table by the prescribed means with the inmate's arms
positioned at an angle away from the inmate's side. Existing closed-circuit monitors will allow
witnesses in the designated witness room to observe this process.

4 The inmate will be positioned to enable the lV Team or the Special Operations Team Leader and the
Warden to directly observe the inmate and to monitor the inmate's face with the aid of a high
resolution color camera and a high resolution color monitor.

5 After the inmate has been secured to the execution table, the Restraint Team Leader shall personally
check the restraints which secure the inmate to the table to ensure they are not so restrictive as to
impede the ¡nmate's circulation, yet sufficient to prevent the inmate from manipulating the catheter
and lV lines.

6 A microphone will be affixed to the inmate's shirt to enable the lV Team or the Special Operations
Team Leader to hear any utterances or noises made by the inmate throughout the procedure. The
Special Operations Team Leader will confirm the microphone is functioning properly, and that the
inmate can be heard in the chemical room.

7 The Restraint Team members will attach the leads from the electrocardiograph to the inmate's chest
once the inmate is secured. The lV Team Leader shall confirm that the electrocardiograph is
functioning properly and that the proper graph paper is used. A backup electrocardiograph shall be
on site and readily available if necessary. Prior to the day of and on the day of the execution both
electrocardiograph instruments shall be checked to confirm they are functioning properly.

8 An lV Team member shall be assigned to monitor the EKG, and mark the EKG graph paper at the
commencement and completion of the administration of the lethal chemical(s) .

9 Throughout the procedure, the lV Team Leader shall monitor the inmate's level of consciousness and
electrocardiograph readings utilizing direct observation, audio equipment, camera and monitor as well
as any other medically approved method(s) deemed necessary by the lV Team Leader. The lV Team
Leader shall be responsible for monitoring the ¡nmate's level of consciousness.

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10 Existing closed-circuit monitors will allow witnesses in the designated witness room to observe the
lV Team's vein assessment and placement of lV catheters in the inmate. ln addition, the audio feed
from the overhead microphone will be turned off following the lV Team's assessment and placement
of lV catheters.

11 A camera will be focused on the area in the chemical room in which syringes are injected into the lV
line, and existing closed-circuit monitors will allow witnesses in the designated witness room to
observe the administration of the lethal injection drug(s), including the administration of add¡tionalor
subsequent doses of the drug(s). All cameras and monitors shall be placed in such a manner so as to
ensure and preserve at all times the anonymity of all personnel involved in the execution process.

E. lntravenous Lines

1 The Director acting upon the advice of the lV Team Leader shall determine the catheter sites. A
femoral central line shall only be used if the person inserting the line is currently qualified by
experience, training, certification or licensure w¡thin the Un¡ted States to insert a femoral central
line. The lV Team members shall insert a primary lV catheter and a backup lV catheter.

2 The lV Team Leader shall ensure the catheters are properly secured and properly connected to the lV
lines and out of reach of the inmate's hands. A flow of sterile saline solution shall be started in each
line and administered at a slow rate to keep the l¡nes open.

3 The primary lV catheter will be used to administer the lethal chemical(s) and the backup catheter will
be reserved in the event of the failure of the first line. Any failure of a venous access line shall be
immediately reported to the Director.

4. The lV catheter in use shall remain visible to the Warden throughout the procedure.

5 The Warden shall physically remain in the room with the inmate throughout the administration of the
lethal chemical(s) in a position sufficient to clearly observe the inmate and the primary and backup
lV sites for any potential problems and shall immediately notify the lV Team Leader and Director
should any issue occur. Upon receipt of such notification, the Director may stop the proceedings and
take all steps necessary in consultation with the lV Team Leader prior to proceeding further with the
execution.

6 Should the use of the backup lV catheter be determined to be necessary, a set of backup chemicals
should be administered in the backup lV.

F. Administration of Chemicals - One-Drug Protocol

At the time the execution is to commence and prior to administering the lethal chemical, the Director
will reconfirm with the Attorney General or designee and the Governor or designee that there is no
legal impediment to proceeding with the execution. Upon receipt of oral confirmation that there is no
legal impediment, the Director will order the administration of the chemical to begin.

2 Upon receipt of the Director's order and under observation of the lV Team Leader, the Special
Operations Team Leader will instruct the assigned Special Operations Team member(s) to begin
dispensing the chemicals under the chosen drug protocol.

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3 Upon direction from the Special Operations Team Leader, the assigned Special Operations Team
member will visually and orally confirm the chemical name on the syringe and then administer the
first syringe of the sterile saline solution, followed by the full dose of the lethal chemical immediately
followed by the sterile saline solution flush.

4. When three minutes has elapsed since commencing the administration of the lethalchemical, the lV
Team Leader, dressed in a manner to preserve their anonymity, will enter ¡nto the room where the
Warden and inmate are located to physically confirm the inmate is unconscious by using all
necessary medically appropriate methods, and verbally advise the Director of the same. The lV Team
Leader will also confirm that the lV line remains affixed and functioning properly.

5 lf, after three minutes, the inmate remains conscious, the lV Team shall communicate th¡s
information to the Director, along with all lV Team input. The Director will determine how to proceed
or, if necessary, to start the procedure over at a later time or stand down. The Director may direct
the curtains to the witness viewing room be closed, and, if necessary, for witnesses to be removed
from the facility, only in the event of a legitimate penological objective which would merit such
closure and/or removal.

6 lfdeemed appropriate, the Director may instruct the Special Operations Team to administer an
additional dose of the lethal chemical followed by the sterile saline solution flush. This may be
administered via the primary or backup lV catheter, as determined following consultation with the lV
Team.

7 Upon administering the lethal chemical and sterile saline solution from a backup set, the lV Team
shall determine whether the inmate is unconscious by sight and sound, utilizing the audio equipment,
camera and monitor. The lV Team Leader will again physically determine whether the inmate ¡s
unconscious using proper medical procedures and verbally advise the Director of the same.

8 When all electrical act¡vity of the heart has ceased as shown by the electrocardiograph, the lV Team
Leader will confirm the inmate is deceased and the inmate's death shall be announced by the
Director.

o The Special Operations Team Recorder shall document on the Correctional Services Log the start and
end times of the administration of the lethal chemical.

10 Throughout the entire procedure, the lV Team members, the Special Operations Team members and
the Warden shall continually monitor the inmate using all available means to ensure that the inmate
remains unconscious and that there are no complications.

G. Administration of Chemicals - Three-Drug Protocol

At the time the execution is to commence and prior to administering the chemicals, the Director will
reconfirm with the Attorney General or designee and the Governor or designee that there is no legal
impediment to proceeding with the execution. Upon receipt of oral conf irmation that there is no legal
impediment, the Director will order the administration of the chemicals to begin.

2 Upon receipt of the Director's order and under observation of the lV Team Leader, the Special
Operations Team Leader will instruct the assigned Special Operations Team member(s) to begin
dispensing the first chemical.

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3 Upon direction from the Special Operations Team Leader, the assigned Special Operations Team
member will visually and orally confirm the chemical name on the syringe and then administer the
full dose of Sodium Pentothal immediately followed by the sterile saline flush.

4 When three minutes has elapsed since commencing the administration of the Sodium Pentothal, and
before the Spec¡al Operations Team member(s) begin administering the Vecuronium Bromide/or
Rocuronium Bromide/or Pancuronium Bromide, the lV Team Leader, dressed in a manner to preserve
their anonymity, will enter into the room where the Warden and inmate are located to physically
confirm the inmate is unconscious by using all necessary medically appropriate methods, and
verbally advise the Director of the same. The lV Team Leader will also confirm that the lV line
remains affixed and functioning properly.

5 No further chemicals shall be administered until the lV Team Leader has confirmed the inmate is
unconscious, has verbally advised the Director and three minutes have elapsed since commencing
the administration of the Sodium Pentothal.

6. ln the unlikely event that the inmate is conscious, the lV Team shall assess the situation to
determine why the inmate is conscious. The lV Team Leader shall communicate this information to
the Director, along with all lV Team input. The Director will determine how to proceed, limited to
the option provided in Attachment D, 5 G(7), or to stand down. lf the Director determines to stand
down, then trained medical staff shall make every reasonable effort to revive the inmate. The
Director may direct the curtains to the witness viewing room be closed, and, if necessary, for
witnesses to be removed from the facility, only in the event of a legitimate penological objective
which would merit such closure and/or removal.

7 lf deemed appropriate, following consultation with the lV Team, the Director may instruct the
Special Operations Team to administer the Sodium Pentothal from Bank "8", either via the primary
access point or through the backup site, followed by the sterile saline flush.

8 Upon administering the Sodium Pentothal and sterile saline solution from a Backup Set, the lV Team
shall determine whether the inmate is unconscious by sight and sound, utilizing the audio equipment,
camera and monitor. The lV Team Leader will again physically determine whether the inmate is
unconscious using proper medical procedures and verbally advise the Director of the same.

I Only after receiving oral confirmation from the lV Team Leader that the inmate is unconscious and
three minutes have elapsed since commencing the administration of the Sodium Pentothal and sterile
saline solution, will the Director instruct the Special Operations Team Leader to proceed with
administering the next chemicals.

10 When instructed, the Special Operations Team Leader will instruct the assigned Special Operations
Team members to begin administering the full doses of the remaining chemicals, each followed by a
sterile saline flush.

11 When all electrical activity of the heart has ceased as shown by the electrocardiograph, the lV Team
Leader will confirm the inmate is deceased and the inmate's death shall be announced by the
Director.

12 The Special Operations Team Recorder shall document on the Correctional Services Log the start and
end times of each of the three phases of the administration of the chemicals.

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13 Throughout the entire procedure, the lV Team members, the Special Operations Team members and
the Warden shall continually monitor the inmate using all available means to ensure that the inmate
remains unconscious and that there are no complications.

H. Contingency Procedure

An Automated External Defibrillator (AED) will be readily available on site in the event that the
inmate goes into cardiac arrest at any time prior to dispensing the chemicals; trained medical staff
shall make every effort to revive the inmate should this occur.

2 Trained medical personnel and emergency transportation, neither of which is involved in the
execution process, shall be available in proximity to respond to the inmate should any medical
emergency arise at any time before the order to proceed with the execution is issued by the
Director.

3 lf at any po¡nt any team member determines that any part of the execution process is not going
according to procedure, they shall advise the lV Team Leader who shall immediately not¡fy the
Director. The Director may consult with persons deemed appropriate and will determine to go
forward with the procedure, limited to the option provided in Attachment D, 5 G(7) or 5 F(6), or to
stand down. lf the Director determines to stand down, then trained medical staff shall make every
reasonable effort to revive the inmate.

4 There shall be no deviation from the procedures as set forth herein, except as expressly allowed
herein. There shall be no deviation from the procedures as set forth herein without prior consent
from the Director. Although such consent may be verbal or in writing, the Director must memorialize
and maintain a written record of having granted any deviations, which record must include a detailed
description of the deviation, the bas¡s for the deviation, and the basis for the Director's consent
thereto.

L Post Execution Procedures

1 Upon the pronouncement of death, the Director shall notify the Governor or designee and the
Attorney General or designee via telephone that the sentence has been carried out and the time that
death occurred.

2 An lV Team member will clamp and cut the lV lines leaving them connected to the inmate for
examination by a Medical Examiner.

3 A Criminal lnvestigations Unit lnvestigator and a Medical Examiner will take photos of the inmate's
body:

a While in restraints prior to being placed in the body bag,

a Without restrains prior to being placed in the body bag,
a Sealed in the body bag, and
a A photo of the seal in place on the bag.

4 The inmate's body will be placed on a Medical Examiner's gurney and released into the custody of a
Medical Examiner's Office.

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5 it will be escorted off

Once the inmate's body is placed in a Medical Examiner's transport vehicle,
the premises. The Examiner's Office will take the inmate's body to the medical examiner's office
designated by the county.

J. Documentation of Chemicals and Stay

1 ln the event that a pending stay results in more than a two hour delay, the catheters shall be
removed, if applicable, and the inmate shall be returned to the holding cell until further notice.

2 The Correctional Service Logs the list of identifiers and the EKG tape shall be submitted to the
Department's General Counsel for review and storage.

K. Debrief and Policy Review

1 The lV and Special Operations Teams will participate in an informal debriefing ¡mmediately upon
completion of the event.

2, Upon an assignment to a Team, team members shall review Departm ent Order #71O, Execution
Procedures

3. Periodically, and in the d¡scret¡on of the Director, a review of Department Order #710, Execution
Procedures alon g with this attachment may be reviewed to confirm it remains consistent with the
law. General Counsel shall advise the Director immediately upon any change that may impact these
procedures.

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