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VI. Botched Executions

A number of lethal injection executions have gone terribly, visibly wrong. Michael Radelet, a professor of sociology and law, has compiled a list of thirty-six “botched executions,” which he defines as executions where there is the appearance of “prolonged suffering” on the part of the condemned inmate “for twenty minutes or more.”217 Because states do not make public, maintain, or even keep records of their executions (see the “U.S. Constitutional Law” section of Chapter Seven), this list was developed from media reports. There may be other botched executions that were never reported. In addition, there is no way to know how many prisoners killed by lethal injections suffered needlessly, but invisibly, because of inadequate anesthesia masked by a neuromuscular blocking agent.

Lethal injection executions where the condemned inmate’s suffering was visible to the witnesses include:

  • Stephen Peter Morin, executed in Texas on March 13, 1982. Execution technicians probed Morin’s veins over and over again for forty-five minutes before they found a suitable vein to establish an intravenous line. Like many death row inmates, Morin had a history of injection drug abuse that had left his veins compromised, making them difficult to penetrate with a needle.218
  • Raymond Landry, executed in Texas on December 13, 1988. Two minutes after the injection of the drugs into Landry began, the catheter dislodged out of his vein and flew through the air. Officials pulled the curtain separating the witnesses from the inmate. Operating from behind the curtain, it took the execution team fourteen minutes to reinsert the catheter into the vein. Witnesses reported hearing at least one “groan” from Landry from behind the curtain. Twenty-four minutes after the intravenous drugs were injected, and forty minutes after being strapped to the execution gurney, Landry was pronounced dead. A spokesperson for the Texas Department of Criminal Justice explained afterwards, “There was something of a delay in the execution because of what officials called a ‘blowout.’ The syringe came out of the vein, and the warden ordered the team to reinsert the catheter into the vein.”219
  • Stephen McCoy, executed in Texas on May 24, 1989. McCoy had a violent physical reaction to the lethal injection drugs. During the execution, his chest heaved up and down as he gasped for breath, choked, and arched his back up and off the gurney. The Texas Attorney General admitted that the inmate “seemed to have a somewhat stronger reaction,” than other executed prisoners, adding “The drugs might have been administered in a heavier dose and more rapidly.”220
  • Charles Walker, executed in Illinois on September 12, 1990.  According to Gary Sutterfield, an engineer from Missouri State Prison retained by the State of Illinois to assist in Walker’s execution, a kink in the plastic tubing going into the inmate’s arm stopped the chemicals from reaching Walker. In addition, the intravenous needle was incorrectly inserted pointing at Walker’s fingers instead of his heart. The incorrect insertion delayed the flow of drugs to Walker’s heart, prolonging the execution.221
  • Ricky Ray Rector, executed in Arkansas on January 24, 1992. It took medical staff, with Rector’s help, more than fifty minutes to find a suitable vein in Rector’s arm. The curtain remained closed between Rector and the witnesses, but some reported they could hear Rector moaning. The administrator of the State Department of Corrections Medical Program said “the moans did come as a team of two medical people that had grown to five worked on both sides of his body to find a vein. That may have contributed to his occasional outbursts.” The state later attributed the difficulty in finding a suitable vein to Rector’s heavy weight and to his use of an antipsychotic medication.222
  • John Wayne Gacy, executed in Illinois on May 10, 1994. After the execution began, the chemicals unexpectedly solidified in the IV tube leading to Gacy’s arm, clogging it, and stopping the chemicals from flowing to his vein. Officials drew the blinds covering the window through which the witnesses were observing the execution, while the execution team replaced the clogged tube with a new one. Ten minutes later, the blinds were reopened, and the execution process began again. It took eighteen minutes to complete. In news reports, anesthesiologists blamed the problem on the inexperience of prison officials who were conducting the execution, noting that even simple procedures taught in an “IV 101” class would have prevented the error.223
  • Emmit Foster, executedin Missouri on May 3, 1995. Seven minutes after the lethal chemicals began to flow into Foster’s arm, the chemicals stopped flowing through the tube. With Foster gasping and convulsing, the execution was halted, and the blinds covering the window between the witnesses and Foster were drawn. The execution proceeded behind the blinds. Thirty minutes later, Foster was pronounced dead. Three minutes later the curtains were opened so the witnesses could view the corpse. The coroner who pronounced Foster dead explained that Foster had been too tightly strapped to the gurney, restricting the flow of the chemicals into his veins. A corrections staff member, upon the coroner’s recommendation, finally loosened the straps, and Foster died several minutes after that.224
  • Tommie J. Smith, executed in Indiana on July 18, 1996. Smith’s small veins made it difficult for the execution technicians to find a suitable vein, and a physician was called in. Smith was given a local anesthetic, and the physician twice attempted to insert a catheter into Smith’s neck. When that failed, the angio-catheter was inserted in Smith’s foot. Only then were witnesses allowed to observe the process. The lethal drugs were finally injected into Smith forty-nine minutes after the first attempts, and it took another twenty minutes before his death was pronounced.225
  • Michael Eugene Elkins, executed in South Carolina on June 13, 1997. Because Elkin’s body was swollen from liver and spleen problems, it was difficult for the executioners to locate a suitable vein for the catheter insertion. The executioners ultimately probed for a vein in his neck. Elkins tried to assist the executioners, asking, “Should I lean my head down a little bit?” as they probed for a vein. After numerous failures, a usable vein was found.226
  • Joseph Cannon, executed in Texas on April 23, 1998.  After Cannon made his final statement, the execution process began. A vein in Cannon’s arm collapsed and the needle popped out. Seeing this, Cannon lay back, closed his eyes, and exclaimed to the witnesses: “It’s come undone.” Officials then pulled a curtain back to block the view of the witnesses, reopening it fifteen minutes later, when a weeping Cannon made a second final statement and the execution resumed.227
  • Claude Jones, executed in Texas on December 7, 2000. It took the execution team thirty minutes to find a suitable vein, in part because of Jones’s history of drug abuse. Warden Jim Willet, the man in charge of the execution, stated:

The medical team could not find a suitable vein. Now I was really beginning to worry. If you can’t stick a vein then a cut-down [where a cut is made into the vein to insert the chemicals] has to be performed. I have never seen one and would just as soon go through the rest of my career the same way. Just when I was really getting worried, one of the medical people hit the vein in the left leg.228

  • Jose High, executed in Georgia on November 7, 2001. High was pronounced dead some one hour and nine minutes after the execution began. After attempting to find a useable vein for thirty-nine minutes, the emergency medical technicians under contract to do the execution abandoned their efforts. Eventually, one needle was stuck in High’s hand, and a physician was called in to insert a second needle between his shoulder and neck.229

Because of recent litigation in North Carolina challenging that state’s lethal injection protocol, evidence of a number of botched executions in that state have recently become public:

  • Willie Fisher, executed in North Carolina on March 9, 2001. After appearing to lose consciousness, Fisher began convulsing, and his eyes opened. A witness described Fisher as trying to catch his breath, with his chest heaving repeatedly.230
  • Eddie Ernest Hartman, executed in North Carolina on October 3, 2003. As the drugs were being administered, Hartman’s throat began alternately thrusting outward and collapsing inward. His neck pulsed, bulged, and shook repeatedly. Hartman’s eyes were open, and his body convulsed and contorted throughout the execution until he died.231
  • John Daniels, executed in North Carolina on November 14, 2003. Daniels lay still as the warden announced that the execution would proceed. Then suddenly, he started to convulse. He sat up, and witnesses could hear him gagging through the glass that separated him from them. After laying down again for a brief time, he sat up, gagged, and choked, while his arms appeared to be struggling underneath the sheet covering him.232

Even when lethal injections have appeared to proceed smoothly, however, they may nonetheless have involved considerable pain and suffering. The inability to ascertain whether or not more prisoners have suffered during their executions stems from the use of pancuronium bromide, which prevents the prisoners from communicating verbally or physically what they are experiencing. Witnesses to the execution see a person lying quietly; they have no way of knowing whether he is in fact properly anesthetized or whether he is experiencing excruciating pain behind his paralyzed face.

Execution records—e.g., execution logs, autopsies, and toxicology reports—are necessary to conduct accurate post-mortem reviews of how the execution proceeded, including whether the prisoner reached an appropriate level of anesthesia.233 But corrections agencies have refused to create or keep such records, and agencies have refused to make them publicly available when they have been created or kept.234 For example, Texas, which has conducted 362 lethal injection executions, the most in the United States,235 stopped conducting autopsies of its executed prisoners in 1989.236

Execution logs from California—the only state in which such records have been made publicly available, and only because of litigation—strongly suggest that lethal injection executions in that state are not going according to plan.           When a barbiturate like sodium thiopental is used during surgery, the patient goes limp within seconds after the drug begins flowing into his veins.237 He may take a few breaths, cough, hiccup, or have some erratic breathing, but there would be no regular and ongoing up and down chest movements.238 The anesthesia removes the patient’s ability to breathe on his own, which is why a doctor will intubate him so that a machine can do his breathing for him during surgery.239 Yet in California, six recent lethal injection execution logs indicate that prisoners were breathing more than a minute after they should have received a dose of sodium thiopental ten times that used in surgery.240 According to the execution logs:241

  • Jaturun Siripongs was executed on February 9, 1999. The administration of sodium thiopental began at 12:04 a.m., and the administration of pancuronium bromide began at 12:08 a.m., yet breathing did not cease until 12:09 a.m., four minutes after the administration of sodium thiopental began and one minute after the administration of pancuronium bromide began.
  • Maunuel Babbitt was executed on May 4, 1999. The administration of sodium thiopental began at 12:28 a.m., and the administration of pancuronium bromide began at 12:31 a.m., yet respirations did not cease until 12:33 a.m., five minutes after the administration of sodium thiopental began and two minutes after the administration of pancuronium bromide began.
  • Darrell Keith Rich was executed on March 15, 2000. The administration of sodium thiopental began at 12:06 a.m., and the administration of pancuronium bromide began at 12:08 a.m., yet respirations did not cease until 12:08 a.m., when pancuronium bromide was injected, two minutes after the administration of sodium thiopental began.242
  • Stephen Wayne Anderson was executed on January 29, 2002. The administration of sodium thiopental began at 12:17 a.m., and the administration of pancuronium bromide began at 12:19 a.m., yet respirations did not cease until 12:22 a.m., five minutes after the administration of sodium thiopental began and three minutes after the administration of pancuronium bromide began.
  • Stanley Tookie Williams was executed on December 13, 2005. The administration of sodium thiopental began at 12:22 a.m.; the administration of pancuronium bromide began at 12:28 a.m.; and the administration of potassium chloride began at 12:32 or 12:34 a.m. (there is some discrepancy in the execution log as to when the potassium chloride was administered); yet respirations did not cease until either 12:28 a.m. or 12:34 a.m. (again there is an inconsistency in the records), either six or twelve minutes after the administration of the sodium thiopental began, either at the same time as or six minutes after the administration of pancuronium bromide began, and either four minutes before or at the same time as the administration of potassium chloride began.243
  • Clarence Ray Allen was executed on January 17, 2006. The administration of sodium thiopental began at 12:18 a.m., yet respirations did not cease until 12:27 a.m., when pancuronium bromide was injected, nine minutes after the administration of sodium thiopental began.

The logs do not prove that these six men were conscious when the pancuronium bromide and potassium chloride were injected. But the fact that their breathing did not stop when expected suggests adequate doses of sodium thiopental may not have been administered. At the very least, the logs point to the importance in three-drug lethal injection executions of having someone present to establish the level of anesthesia before the second and third drugs are administered.

Eyewitness testimony about lethal injection executions in Texas also raises concerns some prisoners in Texas were breathing after the administration of the sodium thiopental should have paralyzed their lung muscles. Reverend Carroll Pickett witnessed ninety-five lethal injection executions in Texas from 1982 through 1995.244 As the condemned inmate’s spiritual advisor on the day of his execution, Pickett stayed with the inmate throughout the execution until the inmate died. Once the inmate was on the gurney, Pickett stood next to him, his right hand touching the inmate’s right knee. During some of the executions, he “saw some of the boys with their eyes open and looking at me after the thiopental came, I felt like I let [the prisoner] down, because the execution was not proceeding exactly as I told [the prisoner].”245 Human Rights Watch asked Pickett if he signaled anything to the warden when he noticed a prisoner’s eyes open. He said no, that it had not been clear to him that something was wrong.246 When asked if he remembered any of the inmates breathing after the administration of the sodium thiopental, Pickett said that he “did not see any of them stop breathing after that. That just put them to sleep. But they kept breathing. All of them.”247 

Pickett did not have any medical training; he had not been asked to monitor the condemned inmates breathing; and the executions were many years ago. Nevertheless, his memory of open eyes and breathing prisoners suggests there in fact may have been serious problems with the way Texas executed its prisoners. 

[217] See Michael Radelet, “Post-Furman Botched Executions,” (retrieved April 5, 2006). Also: Human Rights Watch telephone interview with Michael Radelet, professor of sociology, University of Colorado at Boulder, Boulder, Colorado, March 1, 2006.

[218] “Murderer of Three Women is Executed in Texas,” p. 9.

[219] “Landry Executed for ’82 Robbery-Slaying,” Dallas Morning News, December 13, 1988, p. 29A.

[220] “Witness to an Execution,” Houston Chronicle, May 27, 1989, p. 11.

[221] “Niles Group Questions Execution Procedure,” United Press International, November 8, 1992.

[222] “Joe Farmer, Rector, 40, Executed for Officer’s Slaying,” Arkansas Democrat-Gazette, January 25, 1992, p. 1B; Sonja Clinesmith, “Moans Pierced Silence During Wait,” Arkansas Democrat Gazette, January 26, 1992, p. 1B; Marshall Frady, “Death in Arkansas,” The New Yorker, February 22, 1993, p. 105.

[223] Rob Karwath and Susan Kuczka, “Gacy Execution Delay Blamed on Clogged IV Tube,” Chicago Tribune, May 11, 1994, p. 1 (Metro Lake Section).

[224] Tim O’Neil, “Too-Tight Strap Hampered Execution,” St. Louis Post-Dispatch, May 8, 1995, p. 6B.

[225] Sheri Edwards and Suzanne McBride, “Doctor’s Aid in Injection Violated Ethics Rule: Physician Helped Insert the Lethal Tube in a Breach of AMA’s Policy Forbidding Active Role in Execution,” Indianapolis Star, July 19, 1996, p. A1.

[226] “Killer Helps Officials Find A Vein At His Execution,” Chattanooga Free Press, June 13, 1997, p. A7.

[227] “1st Try Fails to Execute Texas Death Row Inmate,” Orlando Sentinel, April  23, 1998, p. A16; Michael Graczyk, “Texas Executes Man Who Killed San Antonio Attorney at Age 17,” Austin American-Statesman, April 23, 1998, p. B5.

[228] Sarah Rimber, “Working Death Row,” New York Times, December 17, 2000, p. 1.

[229]  Rhonda Cook, "Gang leader executed by injection Death comes 25 years after boy, 11, slain" Atlanta Journal Constitution, November 7, 2001, p. B1.

[230] Order. Brown v. Beck, No. 5:06-CT-3018-H, April 7, 2006, p. 9.

[231] Ibid., p. 10.

[232] Ibid.

[233] In April of 2005, a team of medical doctors reported in the British medical journal The Lancet that toxicology reports on forty-three of forty-nine executed inmates revealed the anesthetic administered during lethal injections was lower than that required for surgery. Indeed, in twenty-one of the inmates, the concentrations of thiopental in the blood were consistent with awareness. The report concludes, "Failures in protocol design, implementation, monitoring and review might have led to the unnecessary suffering of at least some of those executed. Because participation of doctors in protocol design or execution is ethically prohibited, adequate anesthesia cannot be certain. Therefore, to prevent unnecessary cruelty and suffering, cessation and public review of lethal injection is warranted." G. K. Leonidas, et al., “Inadequate Anesthesia in Lethal Injection for Execution,” The Lancet, Vol.365 (9468), April 16, 2005, p.1412.  Medical experts have subsequently discredited the Lancet report because the blood used in the toxicology analysis was drawn many hours after the execution. To be most accurate, blood used for a toxicology analysis would have to be drawn soon after the prisoner’s death. See, e.g., “Study: Lethal Injection Not Painless,” Chicago Tribune, April 15, 2005, (retrieved April 2, 2006).

[234] See, for instance, policies in Missouri, Louisiana, and North Carolina: Missouri does not keep any records from its executions (Defendant Crawford’s Answers to Plaintiff’s First Interrogatory, Taylor v. Crawford, Case No. 05-4173-CV-C-SOW, September 12, 2005, p. 24); Louisiana does not keep its execution records for more than five years (Inglis Deposition, p. 57); North Carolina does not keep any execution records either (Testimony of Polk, p.114).

[235] DPIC, “Execution Database.”

[236] Harris v. Johnson, et al., April 15, 2004, p. 5.

[237] Interview with Heath, March 6, 2006; Interview with Dershwitz, March 1, 2006.

[238] E-mail correspondence to Human Rights Watch from Dershwitz, March 9, 2006.

[239] Ibid.

[240] Doses of sodium thiopental used in surgery are typically one-tenth the five grams called for in California’s lethal injection executions at the time of these six executions. San Quentin Procedure No. 770, p. 32. California has since changed its dosage of sodium thiopental, from five grams to 1.5 grams. See Chapter Five on the Morales v. Hickman case.

[241] It is unclear who was responsible for keeping the execution log and what the protocol was for determining when respirations ceased. E-mail correspondence to Human Rights Watch from John Grele, attorney for Morales, April 1, 2006. (Copies of the six execution logs are on file with Human Rights Watch.)

[242] The execution log states that Rich’s respirations ceased at 12:08 a.m., but notes that Rich had “chest movements” lasting from 12:09 to 12:10 a.m. These chest movements began after Rich had supposedly stopped breathing and three minutes after the administration of the thiopental. The chest movements are “consistent with an attempt to fight off the accruing paralytic effect of the pancuronium.” Third Declaration of Dr. Mark Heath, Morales v. Hickman, February 9, 2006, p. 6.

[243] The records are inconsistent. The formal execution log suggests that Williams stopped breathing at 12:28 a.m. and indicates that potassium chloride was injected at 12:32 a.m., whereas the execution team’s log states that Williams stopped breathing at 12:34 a.m., when the potassium chloride was injected. It appears that the formal log was altered without any indication as to who made the alteration.

[244] Interview with Pickett.

[245] Ibid.

[246] Ibid.

[247] Ibid.

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