Botched Lockett Execution Blamed on IV Placement

OKLAHOMA CITY (CN) - Clayton Lockett writhed in agony during his execution this past April because the intravenous line on his crotch was placed improperly but covered with a sheet, Oklahoma prison officials revealed.

Lockett's reaction to the groin injection of controversially sourced drugs on April 29 resulted in the abrupt halt of his execution. Prison officials quickly drew the blinds in the execution chamber, and Lockett died approximately 20 minutes later.

The 38-year-old was on death row for raping Stephanie Neiman, 19, shooting her with a sawed-off shotgun and watching while two accomplices buried her alive.

Public outcry over the botched execution led Oklahoma Gov. Mary Fallin to order an investigation.

In a 29-page report released Thursday, Oklahoma Department of Public Safety officials blamed the mishap on an IV line that failed to deliver the drugs into his bloodstream. The drugs had instead pooled in the tissue of Lockett's groin.

Officials had used a groin vein because they were unable to tap veins elsewhere on Lockett's body, according to the report.

Warden Anita Trammell ordered Lockett's groin and the IV line insertion area covered with a sheet to "maintain Lockett's dignity and keep his genital area covered," the report says.

"From that time, no one had visual observation of the IV insertion point until it was determined that there was an issue and the physicians raised the sheet," the report continues. "Warden Trammell acknowledged it would be her normal duty to observe an IV insertion point for problems. She believed if the IV insertion point had been viewed, the issue would have been detected earlier."

The on-hand physician indicated to Trammell "something was wrong" after syringes of vecuronium bromide and potassium chloride were administered.

"He looked under the sheet and realized the IV had infiltrated," the report says. "At this same time, Warden Trammell viewed what appeared to be a clear liquid and bloog on Lockett's skin in the groin area. The physician observed an area of swelling underneath the skin and described it as smaller than a tennis ball, but larger than a golf ball. The physician believed the swelling would have been noticeable if the access point had been viewed during the process."

After the blinds were drawn, the physician and a paramedic on duty were not sure when the catheter became dislodged and how much of each drug made it into Lockett's vein, according to the report.

"The autopsy indicated elevated concentrations of midazolam in the tissue near the insertion site in the right groin area, which was indicative of the drugs not being administered into the vein as intended," the report says. "Thus, the IV access was not viable as early as the administration of the midazolam."

The report also notes that members of the execution team had felt rushed as there was a second execution scheduled for later in the evening.

Improved observation of IV insertion points is one of several recommendations to Oklahoma execution protocols that the report recommends.

"The IV catheter insertion point should remain visible during all phases of the execution and continuously observed by a person with proper medical training in assessing the ongoing viability of an IV," the report concludes. "Once the appropriate saline infusion has started, it should not be stopped, except for the times that execution drugs are being administered. It should be continuously monitored to assist in ensuring IV viability in accordance with current medical practices and standards."

If prison officials fail to insert an IV after one hour, they should contact the governor for a possible postponement of the execution, according to the report.

The report recommends "formal and continuing" training for execution personal and the establishment of a formal post-execution review of the process. It also urges officials to have additional execution supplies available and contingency protocols put into place to address issues during the execution.

Lockett died one month after the Oklahoma Court of Criminal Appeals delayed his execution because of an ongoing shortage of lethal-injection drugs.

The court concluded that the state's inability to get its usual three-drug cocktail resulted in the need for a revised execution protocol for the replacement drugs.

Lockett's attorney, David Autry, witnessed the execution and said it was "totally botched."

"It was a horrible thing to witness," Autry said at the time. "They should have anticipated possible problems with an untried execution protocol. Obviously, the whole thing was gummed up and botched from beginning to end. Halting the execution obviously did Lockett no good."

Autry was skeptical of prison officials' claims that one of Lockett's veins had blown.

"I'm not a medical professional, but Mr. Lockett was not someone who had compromised veins," Autry said. "He was in very good shape. He had large arms and very prominent veins."

An independent preliminary autopsy conducted by forensic pathologist Dr. Joseph Cohen in June supported Autry's observations. His report noted the "excellent integrity and peripheral and deep veins" for the purpose of an IV insertion. Cohen was unable to find "any significant underlying natural disease" nor a "cardiac condition" that played a role in his death by heart attack.

Several media outlets sued state officials in August over the drawing of the blinds to the execution chamber, deeming it illegal censorship that deprived the press and other witnesses of the right to witness the execution, botch and all.

"The press was also deprived of the opportunity to verify the nature and source of sounds emanating from the execution chamber, which indicated pain and suffering," the lawsuit says. "Because of the state's use of the viewing shade during initial and later stages of Lockett's execution, the press and public received only government-edited access to an important government proceeding. As a result, the press, and by extension the public, were deprived of the First Amendment right of access to observe the initiation and termination of the execution proceeding."

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