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_ LIBRARY
Michigan State
University

 

 

 

This is to certify that the

thesis entitled

SUDDEN lN_-_CUSTODY DEATH AND
POSITIONAL ASPHYXIA

presented by

JOHN FRANCIS KENNEDY

has been accepted towards fulﬁllment
of the requirements for

MASTER OF SCIENCE degree in CRIMINAL JUSTICE

 

 

 

Major professor

Date MAY 184 1999

0-7639 MS U i: an Afﬁrmative Action/Equal Opportunity Institution

 

PLACE IN REI'URN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE

DATE DUE

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use chIRClDatoDm.p65—p.14

SUDDEN lN-CUSTODY DEATH
AND
POSITIONAL ASPHYXIA

By

John Francis Kennedy

A THESIS

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

MASTERS OF SCIENCE
School of Criminal Justice

1999

ABSTRACT

SUDDEN lN-CUSTODY DEATH
AND
POSITIONAL ASPHYXIA

By

John Francis Kennedy

The purpose of this study is to determine the relationship between
positional asphyxia, the hog-tie restraint method, prone positions and sudden in-
custody death. Contemporary administrative, medical, and legal concerns are
identiﬁed. Analysis and evaluation of academic journal articles focus on factors
related to positional asphyxia, in-custody death, prisoner restraint, training, and
policy. An analysis of survey response data obtained from a sample of large law
enforcement agencies in the United States is presented to test positional
asphyxia as it relates to various forms of restraint and in-custody deaths.
Suggestions are made in the areas of prisoner restraint, transportation, liability,
policy development, training and equipment in order to aid law enforcement

agencies in their efforts to deal with this phenomenon.

Copyright by
John Francis Kennedy
1999

To my family for their love and support throughout my academic career.
Especially to my parents, my dad and my hero, Bruce D. Kennedy, and my mom,
ltalia Kennedy, for their love, patience, never ending support and conﬁdence in
my abilities, and for always encouraging me to do my best,

I dedicate this research.

ACKNOWLEDGMENTS

Several people have assisted me with the completion of this research. The
efforts of some of these people deserve special mention. First and foremost, I
wish to thank Dr. Daniel 8. Kennedy, my brother, for his guidance and continued
support and cooperation throughout the last several years. I am especially
grateful for his unconditional support and guidance.

I wish to thank Dr. David L. Carter, my advisor and committee chair, and
Dr Dennis M. Payne for their continued support, guidance, insight and dedication.
They have made my graduate study a pleasurable and rewarding experience.

I would also like to thank Dr. Christina Dejong and Dr. Sheila R. Maxwell
for providing insight and valuable guidance for this research and for their
assistance.

Lastly, I wish to thank Susan E. Trojanowicz and Hazel A. Harden for
assisting me in many ways throughout my graduate career at Michigan State

University.

TABLE OF CONTENTS

LIST OF TABLES .............................................................................................. VIII
LIST OF ABBREVIATIONS ................................................................................ IX
CHAPTER 1 .......................................................................................................... 1
INTRODUCTION .................................................................................................. 1
Statement of the Problem ............................................................................ 2

The Purpose of the Study ............................................................................ 2
Limitations of the Study ................................................................................ 3
Hypothesis Testing ...................................................................................... 5
Hypothesis ................................................................................................... 5
CHAPTER 2 .......................................................................................................... 7
REVIEW OF THE LITERATURE .......................................................................... 7
Sudden Death .............................................................................................. 7
Causes of Sudden Death ................................................................. 8

Theories to Explain Sudden Death .................................................. 9

Alcohol and Drug Intoxication ........................................................ 11

Adrenaline ...................................................................................... 12

Stress and Respiratory Fatigue ...................................................... 13

Neuroleptic Malignant Syndrome (NMS) ........................................ 13

Risk Factors ................................................................................... 14

Positional Asphyxia .................................................................................... 16
Positional Asphyxia Deﬁned ........................................................... 16

Determining Death by Positional Asphyxia .................................... 21

Risk factors For Positional Asphyxia .............................................. 22

Avoiding Positional Asphyxia ......................................................... 24

Cocaine Intoxication and Excited Delirium ................................................. 25
Cocaine .......................................................................................... 25

Excited Delirium (Cocaine Psychosis) ............................................ 26

Hog-tying ................................................................................................... 30
Restraint .................................................................................................... 34
Investigating Deaths In-custody ................................................................. 35
Invesﬁgaﬁon ................................................................................... 35

Autopsy .......................................................................................... 37

Liability ....................................................................................................... 39
Training ...................................................................................................... 42
Policy Development ................................................................................... 44
Transportation of Prisoners ........................................................................ 46
Prisoner Care ............................................................................................. 48
CHAPTER 3 ........................................................................................................ 50
METHODOLOGY ................................................................................................ 50

vi

Universe of Law Enforcement Agencies .................................................... 50

Sampling Frame ........................................................................................ 51
The Instrument ........................................................................................... 52
Distribution of the Instrument ..................................................................... 52
Data Analysis ............................................................................................. 53
Survey Response ....................................................................................... 53
CHAPTER 4 ........................................................................................................ 55
FINDINGS ........................................................................................................... 55
Responses To The Survey Questions ....................................................... 55
Hypothesis Testing .................................................................................... 59
CHAPTER 5 ........................................................................................................ 66
CONCLUSION .................................................................................................... 66
APPENDIX A ...................................................................................................... 75
SURVEY QUESTIONNAIR INSTURMENT ........................................................ 75
APPENDIX B ...................................................................................................... 81
COVER LETTER TO AGENCIES ....................................................................... 81
APPENDIX C ...................................................................................................... 83
FOLLOW UP LETTER TO AGENCIES ............................................................... 83
BIBLIOGRAPHY ................................................................................................. 85

vii

Table 1.
Table 2.
Table 3.
Table 4.
Table 5.
Table 6.
Table 7.

Table 8.

Table 9.

Table 10.

Table 11.

Table 12.

LIST OF TABLES

Life Situation Categories .................................................................... 10
High Risk Correlates of Sudden ln-custody Death ............................. 16
High Risk Correlates of Excited Delirium (Cocaine Psychosis) .......... 27
Possible Explanations for Deaths when Hog-tied .............................. 32
Response Rate - Survey .................................................................... 54
Response Rate - Prohibit Transportation Prone ............................... 56
Response Rate - Prohibit Hog-tying ................................................... 57

Response Rate - Field Ofﬁcers Trained to Recognize

Positional Asphyxia ........................................................................... 58
Response Rate - Deaths Attributed to Positional

Asphyxia Last 5 Years ....................................................................... 59
Prohibit Transport Prone by Deaths Attributed to Positional

Asphyxia Last 5 Years ....................................................................... 61
Prohibit Hog-tying by Deaths Attributed to Positional

Asphyxia Last 5 Years ....................................................................... 62
Field Ofﬁcers Trained to Recognize Positional

Asphyxia by Deaths Attributed to Positional Asphyxia

Last 5 Years ....................................................................................... 65

viii

LIST OF ABBREVIATIONS

ALS ................................................................................... Advanced Life Support.
CPR ..................................................................... Cardiopulmonary Resuscitation.
BJS ............................................................................. Bureau of Justice Statistics.
NMS ................................................................... Neuroleptic Malignant Syndrome.
OC ........................................................................................ Oleoresin Capsicurrn.

Chapter 1

INTRODUCTION

Today, law enforcement ofﬁcers are faced with faced with a criminal
population that is, among other things, becoming more violent, drug abusing, and
gang-afﬁliated (“Sudden in-custody death,” 1996). In order to subdue these
violent and combative individuals, law enforcement personnel commonly use
physical restraints (Chan, Vilke & Neuman, 1998). However, there are many
problems that can be associated with restraining subjects. These problems
generally range from the restraints being "too tight," to seemingly unexplained
sudden in-custody deaths. These sudden in-custody deaths usually occur shortly
after individuals have been restrained and or taken into custody (Pilant, 1996).
When a sudden in-custody death of an arrestee occurs, it is an unexpected and
tragic event that has a signiﬁcant impact on the criminal justice system, the public
and the medical community.

Police ofﬁcers make millions of arrests annually without suspects being
injured or sustaining any severe medical problems. In a small percentage of
these arrests, some suspects suddenly die while in police custody (Ross, 1997).
In 1992, a national survey of 223 law enforcement agencies veriﬁed 94 restraint
related in-custody deaths across the country in period ranging from 1969 through
1992. While these results do not represent a scientiﬁc sampling, it was believed
they are indicative of the prevalence and seriousness of the problem nationwide

(Burgreen, Korosch, Binkerd & Blackboune, 1992). The occurrences of sudden

custodial deaths, however infrequent, can be devastating for agencies and
ofﬁcers alike. No law enforcement agency wants to deal with in-custody death

situations, especially when restraints have been used (Ross, 1997).

Statement of the Problem

There has been a large amount of research that indicates positional
asphyxia has been incorrectly identiﬁed as the primary cause of death for those
persons who die in-custody while handcuffed and placed in a prone position or
hog-tied, resulting in law enforcement agencies and ofﬁcers unjustly held liable.
Thus, the author will test to determine whether agencies that prohibit the
transportation of prisoners in the prone position have any deaths attributed to
positional asphyxia. Also tested will be whether agencies that prohibit the hog-
tying of prisoners have any deaths attributed to positional asphyxia. Finally, the
author will examine whether agencies that train their ﬁeld ofﬁcers to recognize

positional asphyxia have any deaths attributed to positional asphyxia.

The Purpose of the Study

The purpose of this study is to determine the relationship between
positional asphyxia and in-custody deaths in order to help ofﬁcers recognize
factors contributing to this phenomenon, and enable them to respond in a way
that will promote safety and minimize risk of death. This will be accomplished in

two ways.

First, a review of the current academic, medical and legal literature related
to these issues will be presented to further inform and educate ofﬁcers, trainers
and police administrators as to the causes, risk factors, and potential liability
associated with sudden in-custody death. Through ofﬁcer awareness and
resultant action, it is anticipated that deaths attributable to this cause will be
reduced.

Second, an analysis of survey response data obtained from a sample of
large law enforcement agencies in the United States is presented to test
positional asphyxia as it relates to various forms of restraint and in-custody
deaths. The survey instrument was designed to elicit information concerning
positional asphyxia as it relates to in-custody deaths of those persons who have
died while placed in a prone position or hog-tied during initial arrest and
transport. The research hypotheses will be tested, and suggestions will be made
in the areas of prisoner restraint, transportation, liability, policy development,
training and equipment in order to aid law enforcement agencies in their efforts to

deal with this phenomenon.

Limitations of the Study

This study consisted of analysis of data obtained from 118 state and local
police agencies in the United States out of an original sampling frame of 153
agencies. The data were collected by means of a survey questionnaire
instrument designed speciﬁcally to examine positional asphyxia as it relates to

hog-tying, prone positions and in-custody death. The survey questionnaire data

received from the responding law enforcement agencies were subject to
comparative analysis.

In addition, contemporary administrative, medical, and legal concerns
were identiﬁed by a review of the literature currently available. Analysis and
evaluation of academic journal articles focused on factors related to positional
asphyxia, in-custody death, prisoner restraint, training, and policy. The study was
concerned only with these issues in the United States. The method of content
analysis utilized in the study focused only upon the issues the researcher
selected for the study.

Other possible limitations of this study could result from the following
major factors: (1) Deviation in response or a respondent answering a question in
an effort to make his or her department look favorable, (2) provincial and
geographic differences that may not adequately be reﬂected in the questionnaire,
(3) the study was limited to those cities surveyed, (4) low response rate from
those cities surveyed, (5) the method of content analysis utilized in the study was
dependent upon existing data of major criminal justice, medical and legal
publications designed for professional use, (6) the particular philosophy and
beliefs of the publishing organization may have inﬂuenced the subject matter
selected for review in the publications, and (7) the researcher may have
interjected his personal bias in selecting the literary material for review in the

professional publications.

Hypothesis Testing

Statistical analysis theory is used to determine whether hypotheses about
the population are true. The survey instrument includes the two primary groups of
variables contained in the hypothesis statements. These two groups consist of
three independent variables and one dependent variable. The independent
variables describe knowledge of certain police related subjects. They are related
to speciﬁc law enforcement policy and training procedures such as prohibiting
transportation of prisoners in the prone position, prohibiting use of the hog-tie
method, and agencies that train their ﬁeld ofﬁcers to recognize positional
asphyxia. The dependent variable describes whether any agencies had any

deaths attribute to positional asphyxia.

Hypotheses
1. Nuj

There is no signiﬁcant relationship between agencies that prohibit the
transportation of prisoners in the prone position and deaths that could be
attributed to positional asphyxia.

Alternate

There is a signiﬁcant relationship between agencies that prohibit the
transportation of prisoners in the prone position and deaths that could be

attributed to positional asphyxia.

2. Null

There is no signiﬁcant relationship between agencies that prohibit hog-
tying and deaths that could be attributed to positional asphyxia.

Alternate

There is a signiﬁcant relationship between agencies that prohibit hog-tying
and deaths that could be attributed to positional asphyxia.
3. Ngﬂ

There is no signiﬁcant relationship between agencies that train their ﬁeld
ofﬁcers to recognize positional asphyxia and deaths that could be attributed to
positional asphyxia.

Alternate

There is a signiﬁcant relationship between agencies that train their ﬁeld
ofﬁcers to recognize positional asphyxia and deaths that could be attributed to

positional asphyxia.

Chapter 2

REVIEW OF THE LITERATURE

Sudden Death

Since 1985, sudden and unexpected deaths of persons in police custody
have gained increased attention. As a result, many police ofﬁcers and agencies
have been named in lawsuits for alleged wrongful death claims. In many of these
cases, the arresting ofﬁcers used legitimate force techniques to control the
violent subjects when they suddenly died for reasons not directly related to the
physical aspects of restraint or position (Ross, 1997).

Problems can arise for law enforcement agencies when medical
examiners, while performing autopsies, cannot pinpoint the actual cause of
death. Faced with this dilemma, some medical examiners may incorrectly name
positional asphyxia as the primary cause of death, secondary to the forces
applied to the subject by the ofﬁcers just prior to death (Rosazza, 1996). These
secondary forces may include methods of restraint, position of restraint and the
amount of force used to minimize resistance. Plaintiff‘s attorneys are then quick
to place the entire cause of these in-custody deaths on the ofﬁcers and the
agencies when certain restraint techniques, such as hog-tying and prone
positions are used (Gallagher, 1996).

Sudden in-custody death can be deﬁned as any unintentional death that
occurs while a subject is in police or correction custody (Burgreen et al., 1992).

These deaths usually take place after the subject has demonstrated bizarre

and/or violent behavior, and physical force was used to subdue or restrain the
person (Ross, 1997). It is not uncommon for deaths to occur during the
restraining process or while persons are in the restraint position on the ground.
Deaths have also occurred on gurney mattresses or cushioned car seats in the
ﬁeld, and on the ﬂoors of police vehicles (Chan, Vilke, Neuman & Clausen,
1997). Once in police custody, there is a potential for death to occur at any time,
from initial contact with law enforcement ofﬁcers, though the arrest, transport and
booking process.

Whenever sudden death of suspects occurs during arrest or while in
police custody, it is an unexpected and tragic event. Additionally, family, friends,
and citizens all become deeply concerned whenever such a death takes place.
These deaths have a signiﬁcant impact on the criminal justice system and the
medical community, (Ross, 1997). Law enforcement professionals should be
aware that it is very common for damaging rumors to surround these deaths
(Reay, 1998). When police misconduct is alleged there exists a potential for

controversy and major disturbances have erupted (Radelet & Carter, 1994).

Causes of Sudden Death

Sudden deaths of individuals in custody remains a complex issue and
determining the cause of death in these cases is difﬁcult (Chan, Vilke, Newman 8.
Clausen, 1998). The most common cause of sudden death in the general
population of middle aged and older adults is fatal cardiac arrhythmia caused by

pre-existing natural heart disease, usually severe coronary arteriosclerosis (a

chronic disease in which thickening, hardening, and loss of elasticity of the
coronary arterial walls result in impaired blood circulation) (Wutzer, 1995).

Ross (1997) describes two general types of cardiac death or heart attack,
myocardial infarction and arrhythmia. Myocardial infarction occurs as a result of
necrosis or death of muscular cell tissue, of a region of the heart, caused by an
interruption in the blood supply to the heart. Arrhythmia is an uncontrolled burst
of electrical impulses that disrupts the rhythm of the heartbeat and does not
present a clear pathology. Many in-custody deaths resulting from cardiac
arrhythmia, which is believed to be a sizable percentage, cannot be clearly
explained as the end result of heart disease or known risk factors that to lead
heart disease (Ross, 1997). Occasionally such heart disease as coronary
atherosclerosis will be found in someone who dies in-custody while being
restrained and could be the primary cause of death. Coronary atheroscleros is a
form of arteriosclerosis characterized by the deposition of degenerative lipids
containing plaques and cholesterol on the innermost layer of the walls of large

and medium-sized arteries of the heart (Monagan, 1986).

Theories to Explain Sudden 0%

According to Wutzer (1995), there has been an increased interest among
law enforcement practitioners in new theories that attempt to explain sudden
death of those who die while being restrained and in-custody. The majority of
deaths during restraint occur in young males who are able to struggle vigorously

against restraint attempts and who do not have pre-existing heart disease. Engel

(1971) identiﬁes several potential life situations that may induce sudden death
though cardiac failure or heart attack in healthy individuals. These life situations
can be classiﬁed into several categories (see Table 1). Common to these events

is most people will experience them in their lifetime.

 

Table 1.

Life Situation Categories

 

On receiving the news regarding the death of a close person
Observing the collapse or death of a close person

During acute grief; on threat of or loss of a close person
During mourning or on an anniversary

While in personal danger

During threat of injury or after the danger is over

During reunions, triumph or happy endings

 

Some theories propose that a combination involving two instinctual or
biological survival systems are conducive to lethal cardiac events, especially in
those individuals with pre—existing cardiovascular disease. These two survival
systems are identiﬁed as the ﬁght or ﬂight and conservation-withdrawal systems.
Death occurs as a result of either overwhelming excitation (ﬁght or ﬂight), giving
up (conservation-withdrawal) or a combination of the two (Engel, 1971).

Other theories suggest death is a result of victim abnormalities. These

theories rely upon a supposition that persons exhibiting alcohol or drug

10

intoxication, aggressive behavior, mental disorder, minimal response to chemical
agent application or obesity are in some way predisposed to sudden unexpected

death when taken into police or correction custody (Wutzer, 1995).

Alcohol and Drug Intoxication

Perry and McDonough (1995) suggest that sudden in-custody death may
be due to positional asphyxia as a result of alcohol or drug induced
unconsciousness. Because of their intoxicated state and body position, subjects
do not realize they are suffocating (e.g., neck hyper-ﬂexed) and they cannot
place themselves in a better position to breathe.

Acute alcohol and or drug intoxication can decrease respiratory function
by reducing the body’s ability or drive to breathe (Perry & McDonough, 1995).
Subjects may die suddenly from pulmonary asphyxia, inhalation of vomitus
gastric contents, during a convulsion while in transport or after a few hours in
conﬁnement. Alcohol intoxicated subjects experiencing delirium tremens or
seizures pose a greater risk of sudden death (Pilant, 1996). Additionally, the risk
of sudden death is 25 % greater in persons who use both alcohol and cocaine.
The use of cocaine and alcohol creates cardiotoxic effects, which signiﬁcantly
increases the risk of sudden death (Perry & McDonough, 1995). Law
enforcement personnel need to be extremely alert to the intoxicated state of

prisoners during arrest and the initial hours of conﬁnement (Ross, 1997).

11

Adrenaline

Another medical explanation suggests that extreme levels of agitation
caused by fear, panic, anxiety or rage (often demonstrated during arrest)
produces an adrenal hormone (epinephrine or catecholamine) overload (Ross,
1997). A ﬂood of released hormones during a violent struggle can induce
abnormal heart rhythm (Price v. County of San Diego, 1998). A ﬂood of released
hormones, together with preexisting heart disease, hypertensive hearts, drugs,
alcohol, and stress presents a signiﬁcant risk factor for sudden death (Ross,
1997). Also, the consumption of certain drugs, alcohol and stress can also lead
to abnormal heart rhythm (Perry & McDonough, 1995).

When hormones ﬂood the circulatory system during extreme stress and
energy output, tiny cardiac muscle ﬁbers may rupture causing a short-circuit of
the heart's conduction system. Also, an abrupt increase in ﬂow of these adrenal
hormones can cause coronary vessels to constrict requiring the heart to
compensate by pumping in high bursts. These combined effects can result in
ventricular ﬁbrillation, an often fatal form of arrhythmia, characterized by rapid
irregular ﬁbrillar twitching of the ventricles of the heart in place of normal
contractions resulting in a loss of pulse. Once in ventricular ﬁbrillation, death can
occur in minutes. Such deaths many times result in a negative autopsy ﬁnding

(Ross, 1997).

12

Stress and Respiratory Fatigue

Individuals who are in stressful situations can experience abnormal
releases of adrenal hormones causing arrhythmia and sudden death. Research
indicates that in approximately 20 % of arrhythmia cases, individuals have
experienced acute physical stress in the proceeding 24 to 36 hours (Ross, 1997).
Combative subjects who are overwhelmed by the stressful situations during the
struggle against being restrained may experience unexpected respiratory
collapse. The respiratory collapse is believed to be a result of the physical
exhaustion. Struggling violently with ofﬁcers prior to being restrained may place
additional stressors on the heart or make a subject more vulnerable to respiratory
muscle fatigue (Pilant, 1996).

During violent confrontations and struggles, subjects are more vulnerable
to respiratory muscle fatigue because of deﬁcits of energy created by the violent
muscle activity before they are placed in their ﬁnal restrained positions. Stress
can cause sudden cardiac arrest and death (Reay, Flinger, Stilwell & Arnold,

1992).

Neuroleptic Malignant Syndrome (NMS)

In the late 18005, psychotic patients who died suddenly from apparent
natural but undetermined causes were often given the diagnosis of "acute
exhaustive mania” (Wutzer, 1995). Acute exhaustive mania or neuroleptic
malignant syndrome (NMS) is frequently fatal and occurs in people who are

taking anti-psychotic agents or tranquilizing drugs, especially those drugs used in

13

treating mental disorders (Pilant, 1996). Some of the classic symptoms of NMS
are: physical exhaustion; dehydration; muscular rigidity (hypertonicity); elevated
body temperature (hyperthermia); altered consciousness (stupor, coma, etc);
and dysfunction of the autonomic nervous system that controls heart rate, blood
pressure, ventilation and other involuntary functions (Reay et al., 1992).

NMS has been seen in both psychiatric and medical patients. Some
training materials currently in circulation highlight NMS as associated with
sudden in-custody death syndrome. NMS was also described in 1960 as a rare
complication of chemotherapy with anti-psychotic drugs (tranquilizers) such as
haloperidol, and ﬂuphenazine. MNS can develop over a 24-72 hour period. MNS
is not associated with violent acts, criminal offenses or combativeness during
restraint by police. In fact, NMS victims are frequently ill to the point of

incapacitation and are unable to struggle (Wutzer, 1995).

Risk Factors

After reviewing literature on 148 cases from 1970 to 1996, Ross (1997)
determined that the likely candidate of a sudden in-custody death will be male
and approximately 36 years old. He most likely will be stricken on scene or
during transport and die within six hours after the incident. Race does not appear
to be a factor in these deaths. The following aggravating risk factors are
commonly associated with this phenomenon: cocaine, alcohol and/or drug

intoxication; obesity; excited delirium; restraint stress; and maximum fatiguing of

14

the muscular system. Of signiﬁcant importance is alcohol poisoning or acute drug
intoxication (e.g., cocaine and or methamphetamine) (Ross, 1997).

Granﬁeld, Onnen, and Petty (1994) conducted a similar study of 30 in-
custody deaths between August of 1990 and December of 1993. All subjects
behaved in a combative and/or bizarre manner and struggled with the police. In
the majority of these cases drugs and/or alcohol were involved; Oleoresin
Capsicum (OC) spray was either ineffective or less than totally effective. Subjects
were restrained subsequent to OC spraying and deaths occurred either
immediately or soon after the confrontation. Burgreen et al. (1992) suggest that
Law enforcement professionals and police administrators should be aware of
some of the high risk correlates of sudden in-custody death (see Table 2).

Even though in-custody deaths are rare, they tend to share common
elements that occur in some basic sequence. For example, subjects will often
display bizarre, violent or frenzied behavior and, almost always, will be
intoxicated with drugs and/or alcohol (Frost & Hanzlick, 1998). Usually, they will
engage in violent struggles with the police requiring the ofﬁcers to employ some
type of restraint technique. During or immediately after the struggle, the subjects
may become unresponsive, go into cardiopulmonary arrest, and fail to respond to

resuscitation (Granﬁeld et al., 1994).

15

 

Table 2.

High Risk Correlates of Sudden In-custody Death

 

Delirium or psychosis Seizures

Feeling "bugs" on or under skin High blood pressure

Violent behavior High pulse rate
Superhuman strength Aggression toward objects
Dilated pupils Thrashing after restraint
Paranoia Jumping into water
Hallucinations Yelling

Hyperthermia Obesity

Undressing in public Self-inﬂicted injury

Hiding behind objects Hearing voices

Drug & alcohol intoxication

 

Positional Asphyxia

Positional Asphyxia Deﬁned

Dr. Ronald Reay, Chief Medical Examiner in King County Washington,
has written extensively about positional asphyxia since the mid-19803 and is
considered by some as a leading expert regarding this issue. Dr. Reay and his
associates deﬁne positional asphyxia as a position of the body that interferes
with respiration resulting in asphyxia (Reay et al., 1992). More recently, the term
positional asphyxia has been used to describe the deaths of individuals who

were reportedly found in body positions that caused either external airway

16

obstruction, inadequate ventilatory function or interfered with normal breathing
(Chan et al., 1997; Chan, Vilke & Neuman, 1998).

It is important not to confuse positional asphyxia with a similar term known
as “mechanical asphyxia." Mechanical asphyxia is used to describe when actual
mechanical restraints such as vests and jackets accidentally wrap around the
neck of individuals resulting in strangulation (Chan, Vilke & Neuman 1998). Bell,
Valerie, Wetli and Rodriguez (1992) suggest that when describing positional
asphyxia, emphasis should not be put on the restraint methods used such as
hog-tying. Instead positional asphyxia occurs when a subject’s head is in a
hyper-ﬂexed position (e.g., head ﬂexed against an object, restricting breathing).
This is commonly observed, for example, when an alcoholic loses consciousness
as a result of excessive intoxication and falls off of the sofa into a restrictive
position with his or her head and neck ﬂexed against the wall. Intoxicated
individuals have also been found dead with their faces buried in the pillow, sitting
upright with the head ﬂexed or found lying over the side of a bathtub, severely
restricting both diaphragm and chest wall movement (Bell et al., 1992).

Bell et al. (1992) report that death by positional asphyxia involves three
main criteria. First, the decedent must be found in a position that interferes with
pulmonary gas exchange (breathing). This can range from an object covering the
mouth, to the restriction of the diaphragm and chest. Second, there must be an
apparent inability of the person to escape the position. Third, other causes of
death, both natural and unnatural, must be excluded with a reasonable degree of

certainty by means of an autopsy. In all cases of positional asphyxia there should

17

be one or more contributing factors that provide an explanation for the subject’s
inability to correct him or herself from the harmful and potentially lethal position.
Such contributing factors can include alcohol and/or drug intoxication, injury,
illness, physical disability, and entrapment or restraint (Reay et al., 1992).

Measurable physiologic effects have been reported for healthy individuals
who were placed in the maximum restraint or hog-tie position after exercise.
These individuals reportedly experienced a decrease in blood oxygen levels.
Also, prolonged recovery times were required for them to recover to baseline
(normal) heart rates and oxygen saturation levels (Reay, Howard, Filigner &
Ward, 1988). The application of hog-tie type restraint technique and resulting
position of the subject’s body in a conﬁned space were deﬁned as critical factors
leading to respiratory compromise and death (Reay et al., 1992).

According to Reay (1993), death from positional asphyxia in a law
enforcement setting is exceedingly uncommon. However, when such deaths do
occur, the majority take place during police transport situations (Rosazza, 1996).
Some researchers (Granﬁeld et al, 1994) suggest positional asphyxia deaths
tend to occur when subjects are hog-tied, unless seated upright in police
vehicles. These subjects may become quiet and inactive after several minutes of
transport. Respiratory difﬁculty is exhibited, and subjects subsequently stop
breathing. Similarly, Pilant (1996) suggests that positional asphyxia occurs when
a subject is maximally restrained, usually in the hog-tied position, and placed
prone on the ground or on the back seat of the patrol car, thus somewhat

restricting his or her ability to breathe. The harmful positional effect is realized

18

through either interference with muscular respiration, obstruction of the airway or
from some combination of the two.

As a result, positional asphyxia has become signiﬁcantly associated with
sudden in-custody death. Others may have interpreted such reports in the
literature as scientiﬁc evidence that the hog-tie restraint position impedes chest
and abdominal movement thereby causing death by asphyxiation (Chan, Vilke,
Newman & Clausen, 1998). Thus, the common law enforcement practice of
transporting particularly violent suspects in a maximally restrained and prone
position in the back of a police vehicle has been discouraged. It was believed
that these restraint positions generally did not allow for sufﬁcient monitoring of
prisoners. Also the prisoners may not be able to move themselves into another
position to relieve breathing difﬁculty. In response, some law enforcement
agencies have prohibited the transportation of prisoners in the hog-tie or prone
positions (Burgreen et al., 1992).

In contrast, Laposata (1993) suggests that the study reported by Reay et
al. (1988), was incorrect. The evidence presented (the three cases cited) was
insufﬁcient to attribute positional asphyxia alone as the cause of death.
Supporting this argument, Chan et al. (1997) report that oxygenation increases
rather than decreases with exercise. Their ﬁndings were consistent with previous
well-established work on exercise physiology. They found no evidence of hypoxia
(decrease in oxygen) or hypercapnia (increase in carbon dioxide) during exercise
or during rest in the hog-tie position. In fact, hypercapnia decreased.

Furthermore, there was no evidence of ventilatory failure, signiﬁcant

19

hypoventilation (decreased breathing) or asphyxiation as a result of body
positioning while subjects were in the hog-tie position (Chan et al., 1997;
Laposata, 1993).

A more recent study of normal individuals concludes that the hog-tied
prone position should be viewed as not producing signiﬁcant physiologic
respiratory compromise and does not produce any serious or life-threatening
respiratory effects (Reay, 1998). Accordingly, in 1998, pathologist Donald Reay
changed his views on the issue of the hog-tie restraint position. Dr. Reay
acknowledged that the work he had done regarding positional asphyxia and the
hog-tie position was in error stating that in fact there were no problems in terms
of respiratory recovery when just considering the hog-tie position (Price v. County
of Si Dieqo, 1998; “Ruling breathes life,” 1998).

However, this is not to say that positional asphyxia cannot or does not
occur during the arrest, restraint and transportation of subjects. In cases of
positional asphyxia, investigators usually ﬁnd the deceased in a position that
resulted in failure to maintain an open ainNay or adequate breathing function.
(Chan, Vilke & Neuman, 1998; Bell et al., 1992). Most commonly, victims were
found in positions that resulted in upper airway obstruction, including head-neck
hyperﬂexion and lying face down on suffocating objects. Acute alcohol
intoxication was a major risk factor for asphyxiation and may have explained why
many of these individuals were unable to alter their body position to avoid

positional asphyxiation (Perry & McDonough, 1995).

20

Deaths have also been reported involving suspects with acute cocaine
psychosis when they are restrained and placed in a face down or in a prone
position (Reay, 1998). This position is thought to compress the chest and cause
breathing restriction. When death occurs, the position of the body must be
evaluated whenever the person is placed face down and restrained, regardless if
hog-tied or not. However, what is not known is how much the restraint and
position actually contributes to the death (Reay, 1998). The clinical or forensic
relevance of the prone position and the physiologic effects in each case, if any,
requires thoughtful consideration unless, for example, one is prepared to
recommend the sitting position during sleep to prevent asphyxiation (Chan, Vilke,

Newman & Clausen, 1998).

Determininq Death by Positional Asphyxia

According to Bell et al. (1992) and Reay et al. (1992), the diagnosis of
positional asphyxia should be considered when the circumstances surrounding
death indicate the following: (1) The circumstances surrounding death indicate a
body position that could interfere with respiration. This may involve either a
restrictive or conﬁning position or a simple ﬂexion of the head onto the chest. In
either case a partial or complete external ainrvay obstruction or neck compression
is a result of the position and there is no evidence of obvious internal airway
obstruction (e.g., fatal food aspiration). (2) Evidence indicates that the decedent
placed himself or herself in that position inadvertently and without the deliberate

action of another person. (3) The person could not remove himself or herself

21

from the fatal position (e.g., because of chemical intoxication or dementia). (4)
Historical information indicates difﬁculty in breathing or unusual physical
respiratory signs such as cyanosis (bluish discoloration of the skin), gurgling,
gasping or any other physical signs that could be interpreted as evidence of
respiratory distress. (5) There is absence of signiﬁcant or catastrophic anatomic
pathologic changes at autopsy that would conclusively account for death,
including such catastrophic events as intracerebral hemorrhage or myocardial
infraction (ruptured muscular tissue of the heart). (6) There is no evidence of
signiﬁcant cardiac disease. And (7) clearly toxic or fatal levels of drugs or
chemicals that are ordinarily incompatible with life (including carbon monoxide,
cyanide, and lethal levels of therapeutic and abused drugs) are absent from body
ﬂuids.

Reay et al. (1992) suggest that the best explanation for deaths supported
by the previous list of circumstantial events was positional asphyxia.
Furthermore, it is incumbent on the medical examiner and the coroner
responsible for investigating deaths of these types to utilize all of the information
generated during the investigation to identify the appropriate cause of death

(Reay, 1998).

Risk factors For Positional Asphyxia
Over a 9-year period, Bell et al. (1992) studied thirty cases of positional
asphyxia in the Dade and Broward County (Florida) Medical Examiner Ofﬁces. In

the majority of cases, chronic alcoholism or acute alcohol intoxication was

22

determined to be a signiﬁcant risk factor associated with positional asphyxia.
Victims were commonly found in a restrictive position producing hyperﬂexion of
the head and neck.

Bell et al. (1992) revealed several other factors that can increase a
subject's susceptibility to sudden death when restrained or hog-tied. These
factors include obesity, psychosis (e.g., paranoia, schizophrenia, etc.) and drug
or alcohol induced psychotic behavior. In some cases, a large bulbous abdomen
or fat belly is thought to present a signiﬁcant risk because it forces the contents
of the abdomen upward within the abdominal cavity when the body is in a prone
position. This may put pressure on the diaphragm (muscle responsible for
respiration), restricting movement and interfering with a person’s ability to
breathe (Reay, 1996).

It has been also been suggested that mechanical displacement of the
abdomen by the convex contour of the ﬂoor and the edge of the car seat can
accounted for loss of effective diaphragmatic movement preventing adequate
breathing which can lead to hypoxia and death. However, the more likely case of
mechanical displacement of the abdomen occurs when alcoholics are found lying
over the side of bathtubs, thus severely restricting both diaphragm and chest wall
movement (Bell et al., 1992).

Another risk factor suggested for positional asphyxiation is drug or alcohol
induced psychosis. Drugs such as methamphetamine, cocaine and LSD create a
state of delirium frequently accompanied by violent muscular activity. The mind-

altering character of these drugs, combined with the added outbursts of violent

23

and vigorous muscular activity, can cause individuals to lose their breath more
quickly than expected (Chan, Vilke & Neuman, 1998; Reay, 1996; 1998).

Of signiﬁcant importance is alcohol poisoning or acute intoxication. In
many of these cases, subjects are reported to be violent and agitated either from
drug and alcohol intoxication or from psychiatric illness. During transport, the
subjects can become unresponsive and go into cardiopulmonary arrest (Chan,
Vilke & Neuman, 1998). On autopsy, no clear lethal anatomic or toxicological
ﬁndings are usually noted (Rosazza, 1996). Positional asphyxia was believed to
have been the primary cause of death when the hog-tie restraint method was
utilized. However, after complete investigations and autopsies, deaths were
attributed to cocaine intoxication, possibly complicated by other factors including
disease and restraint stress (Chan, Vilke & Neuman, 1998).

Other pre-existing physical conditions can also contribute to positional
asphyxia and sudden in-custody death. Any condition that impairs breathing
under normal conditions will put a subject at a higher risk of respiratory failure
when a situation escalates to the point that hog-tied restraint must be employed.
Heart disease, asthma, emphysema bronchitis and chronic pulmonary disease

fall into this category (Reay, 1996).

Avoiding Posﬁonal Asphyxia
It is not uncommon for subjects to exhibit violent, combative behavior and
ﬁght or struggle with the police (Chan, Vilke & Neuman, 1998). Ofﬁcers should

attempt to determine if the subject used any drugs (e.g., cocaine or

24

methamphetamine) or alcohol. If possible, without exposing the ofﬁcer to any
great risk, the restrained individual should be placed in the lateral position rather
than in the prone position, or sat in an upright position. When the hog-tie restraint
technique is used, there should be enough slack in the restraints to allow for
ventilatory motion of the chest wall muscles. The ofﬁcers must monitor the
restrained subject closely for any signs of becoming suddenly calm and
unresponsive. They must have immediately available means of releasing the
restraints and providing advanced life support service (ALS) when necessary

(Stratton, 1995; Stratton, Rogers & Green, 1995).

Cocaine Intoxication and Excited Delirium

Cocaine

Cocaine is a drug that stimulates the central nervous and cardiovascular
systems. Pharmacologically, cocaine elevates heart rate, constricts blood
vessels, raises blood pressure and increases body temperature. These effects
have produced lethal anatomic catastrophes in individuals without underlying
preexisting anatomic disease(s). Cocaine usage may cause death in
cardiovascular episodes where there is no anatomic abnormality. Seizures and
death have been documented in recreational users who chronically use even
small amounts of cocaine (Granﬁeld et al., 1994).

Long term cocaine abuse produces alterations, hypertrophy (enlargement
of organs) and ﬁbrosis (excessive ﬁbrous tissue) in the heart and brain. These

alterations of the heart and brain are sufﬁcient to cause death even when blood

25

levels of cocaine are negligible (Ross, 1997). Chronic use of cocaine lessens the
brain’s threshold of sensitivity thereby increasing the risk of seizure at any time.
Long term cocaine users are often hyperadrenergic (suffer from high levels of
adrenaline and circulating catecholamines) and may have tachycardia (rapid
heart beats) (Kareh & Wetli, 1995). It is believed that cocaine intoxication is a
contributing factor in approximately 45 percent of the reported sudden death

cases (Ross, 1997).

Excited Delirium (Cocaine Psychosis)

Cocaine induced excited delirium, also known as cocaine psychosis,
results from an acute drug reaction from cocaine. It is commonly associated with
varying quantities of cocaine and is most notable in chronic cocaine abusers.
Excited delirium or psychosis has also been observed in subjects who have
consumed LSD, PCP and methamphetamine. In the forensic literature, cocaine
psychosis is a known risk factor of sudden death and it has been linked to
approximately 37 percent of the deaths that have occurred in-custody (Ross,
1997)

According to Burgreen et al. (1992) and Gallagher (1996), Law
enforcement professionals and police administrators should be aware of some of
the high risk correlates of excited delirium or cocaine psychosis (see Table 3).
These correlates closely resemble many of the same signs and symptoms of
those persons suffering from mental psychosis and those individuals at risk for

sudden in-custody death (see Table 2). Most of the reported cases of excited or

26

agitated delirium have involved young men who were in this state as a result of

intoxication from recreational drugs or psychiatric illness (Ross, 1997).

 

Table 3.

Hiqh Risk Correlates of Excited Delirium(Cocaine Psychosis)

 

Acute onset of bizarre and violent behavior

Hiding in bushes or behind cars
Thrashing after being restrained
Aggression toward objects
Aggression towards glass
Desire to inﬂict self-injury
Combativeness

Extreme paranoia

Delirium or psychosis
Superhuman strength
Hallucinations

Yelling

Hypothermia
Disrobing

Hearing voices
Elevated temperature
Sweating profusely
Foaming of the mouth
Jumping into water
Illusions

Dilated pupils
Aggression

Hyperactivity

 

A signiﬁcant factor in cocaine induced excited delirium is hyperthermia, an

increase in body temperature (Karch & Wetli, 1995). It is not uncommon for the

subject's body core temperature to range from 103 to 106° F (Burgreen et al.,

1992). A good indicator of excited delirium is the detection of drugs such as

cocaine in the blood during autopsy. However, the blood level of cocaine present

in the body can be notably lower than what is commonly observed in fatal
overdoses. Also, mentally ill patients who have stopped taking their medication
may show no indication of drugs in their blood stream and still suffer from excited
delirium (Ross, 1997).

According to Reay (1998), one consequence of excited delirium is that the
subject may be particularly vulnerable to restraint induced sudden death because
excited delirium itself compromises breathing. Positional asphyxia then occurs as
a result of the restraint maneuver and the resting body position of the subject
once breathing is compromised. Thus, the body position must be viewed as
interfering with respiration and the primary factor in the causation of death.
Usually, subjects suffering from positional asphyxia experience brain injury and
cardiac failure within 3 to 5 minutes once respiration is compromised and hypoxia
(lack of oxygen) occurs (Reay, 1998). In other cases, death can be delayed 10 to
20 minutes from the onset of asphyxia. Therefore it is critical to immediately
institute cardiopulmonary resuscitation in an effort to recover function to avoid
hypoxic brain injury and death (Reay, 1998).

Some researchers suggest that the condition of cocaine induced excited
delirium is a potentially lethal medical emergency. High-risk individuals, when in
this manic state, can die regardless of body position no matter how carefully they
are restrained. Increasingly, subjects suffering from cocaine induced excited
delirium are dying in the hospital, despite the immediate availability of medical
equipment and the application of advanced life support (ALS) techniques

(Burgeen et al., 1992). Many individuals suffering from cocaine induced excited

28

delirium die without ever being restrained and are more likely to die in the
summer, especially when the weather is warm and humid. Also, it is not unusual
for subjects to die at the scene or during transport by paramedics to the hospital.
The few victims who live long enough to be hospitalized may succumb to
disseminated intravascular coagulation, rhabdomyoiysis (ﬁbrous tumors), and
kidney failure (Chan et al., 1997).

According to Chan et al. (1997), ilntoxication, breathing compromise,
stress and trauma caused by the excited delirium play a greater role in causation
of death, as opposed to asphyxiation strictly due to body position. The majority of
restrained individuals who die were under the inﬂuence of recreational drugs
(stimulants), such as cocaine and amphetamines (Ross, 1997). These drugs
increase oxygen demand and muscle fatigue and decrease overall respiratory
function. Additionally, many subjects had suffered traumatic injuries and or
emotional stress before and during placement in the restraint position. Generally,
emotional stress leaves no identiﬁable trace during autopsy (Ross, 1997; Stratton
etaL,1995)

When police ofﬁcers are confronted with an individual suffering from
excited delirium, it is not uncommon for that subject to become violent, exhibit
extreme strength, suffer from hyperthermia, and sweat profusely (Burgeen et al.,
1992). The subject may appear to be psychotic and have a signiﬁcantly
diminished sense of pain. Accordingly, police ofﬁcers must restrain such an
individual. Several ofﬁcers are often required for apprehension and arrest due to

the violent struggle that generally ensues. Often, the force used by the police has

29

minimal effect on the subject and he or she continues to struggle after being
restrained. The subject may then suddenly collapse and die, without warning, on
the scene or during transport (Granﬁeld et al., 1994).

Many times when dealing with cocaine intoxication and excited delirium
the mechanism of death appears to be uncertain (Reay, 1996). Death generally
occurs within an hour after the onset of symptoms or after being restrained.
Death frequently occurs in the back of a police car. As previously noted,
hyperthermia seems to be the key in those incidents resulting in death. Persons
with normal or slightly elevated body temperature have a greater chance of
survival (Ross, 1997). Furthermore, the autopsy is generally nonspeciﬁc,
revealing only those injuries sustained from the struggle with the police

(Granﬁeld et al., 1994).

Hog-tying

Law enforcement personnel often encounter individuals who are agitated,
violent and out of control. These individuals may be suffering from a variety of
aliments, such as drug and or alcohol intoxication, excited delirium and emotional
stress (Reay et al., 1992). Generally, they must be subdued or restrained in order
to prevent injury to themselves or others or they must be arrested for the crimes
they have committed. One method commonly used by law enforcement ofﬁcers
to incapacitate an out of control suspect is the hog-tie restraint position
(Rosazza, 1996). The hog-tie restraint position, also known as hobbling, 4-point

restraint or the maximal restraint position, is deﬁned as an individual placed in

30

the prone position with his or her wrists handcuffed or tied together the back, and
ankles bound together and secured to their wrists (Kareh & Wetli, 1995; Reay,
1996).

Recent attention has focused on the use of the hog-tie restraint method
because of the role hog-tying is thought to play in custodial deaths. Reay et al.
(1992) assert that the hog-tie restraint position impairs normal breathing function
by compressing the chest and abdomen, creating an oxygen deﬁcit. Death
results from positional asphyxia due to these adverse physiologic effects.
Additionally, adverse effects are created by the hog-tie, prone, and semi-prone
positions when an individual is placed in a conﬁned space, such as in back of a
police car.

Recent medical literature describes numerous deaths allegedly occurring
when individuals were placed in the hog-tie restraint position while in law
enforcement custody. In many of these cases, the deaths were attributed to
positional asphyxia (Chan, Vilke & Neuman, 1998). Hog—tying has accounted for
approximately 59% of the positional asphyxiation deaths (Ross, 1997).

The theory that hog-tying or simply placing a suspect face-down with
hands cuffed behind the back, after a violent struggle, can cause death by
positional asphyxia is appealing to some forensic pathologists because it assists
them in determining a cause of death when there is no clear anatomic evidence.
The theory also appeals to the families of individuals who die in custody because
it allows them to blame someone other than the deceased (Chan, Vilke &

Neuman, 1998). When a hog-tied subject dies, forensic pathologists generally

31

attribute the death in whole or in part to positional asphyxia resulting from
respiratory compromise (Reay, 1996). Subsequently, this commonly used and
effective technique (hog-tying) has been largely discouraged by many law
enforcement agencies (Pilant, 1996).

The problem with this theory is that no one has conﬁrmed it to be true.
There are no data available to support many of the conclusions drawn in the
case report literature regarding positional asphyxia, hog-tying, individuals placed
in the prone position, and death (Reak, Decker & Gunt, 1998). Pilant (1996)
suggests that other correlates are more important in explaining the deaths of

these individuals (see Table 4).

 

Table 4.

Possible Explanations for Death when Hog-tied

 

Excited delirium Hyperstimulation
Drug alcohol intoxication Muscle fatigue

Catecholamine stress on the heart Alcohol intoxication

Hyperthermia Stress
Physical exhaustion Restraint stress
Trauma

 

Chan, Vilke, and Neuman (1998) indicate that alcohol substantially
increases the risk of sudden death when combined with cocaine. The cardiotoxic

effect of alcohol increase the cardiotoxic effects of cocaine, thus increasing the

32

risk of overdose and death. Alcohol or drug intoxication and a psychotic state can
be a lethal mixture increasing the likelihood of sudden death when a subject is
hog-tied. Some of these correlates closely resemble those of persons at risk for
sudden in-custody death and or suffering from excited delirium or cocaine
psychosis (see Tables 2 and 3). Acute methamphetamine intoxication or excited
delirium is a highly lethal illness that may, in itself, cause death regardless of
whether or not the hog-tie restraint is used or if a struggle was involved.
Additionally, mental patients and persons under the inﬂuence of drugs die while
being restrained in all sorts of positions, including face-up in bed and sitting
upright in chairs (Reak, et al., 1998).

Stratton, Rogers and Green (1995) report that deaths have occurred
without successful resuscitation despite equipped and trained ALS support (ALS)
personnel witnessing the cardiopulmonary arrests and attempting resuscitation.
Supporting this position, Ross (1997) and Chan, Vilke, and Neuman (1998)
suggest that the evidence to cite positional asphyxia alone as a cause of death is
insufﬁcient, and the hog-tie position is not "in itself" a position that would be
expected to be fatal within minutes. Furthermore, Price v. County of San Diegg
(1998), a United States District Court for California has taken the position that
there is no respiratory component to the hog-tie position. If all of the signs and
symptoms of methamphetamine use or excited delirium, absent other
pathological ﬁndings, are present, death will most likely be completely consistent
with toxic delirium secondary to methamphetamine or cocaine use which in turn

causes cardiac arrest. To assume something else would be incorrect.

33

These examples indicate that other factors, not positional asphyxiation as
a result of hog-tying, cause death. Although it may be slightly more difﬁcult to
breathe in a prone position, people survive in such a position all the time, even
when they are highly stressed and exhausted. People sleep on their stomachs,
have sexual intercourse on their stomachs, wrestle on their stomachs and

soldiers ﬁght on their stomachs (Reak et al., 1998).

Restraint

The most common tools that law enforcement ofﬁcers use for effectuating
arrests and controlling disorderly prisoners are restraints. Law enforcement
ofﬁcers generally use restraints to protect themselves, the prisoner, and others
nearby (Stratton, 1995). When using restraints the ofﬁcers must determine the
level or type of restraint that is most appropriate. The level and type of restraint is
usually determined by the actions of the arrestee and the type of vehicle used for
transportation (Rosazza, 1996). Also, during the arrest and restraint process, the
responding ofﬁcers cannot be responsible for recognizing or diagnosing the
underlying cause of the subject’s disturbed behavior. In many cases it is not
possible for the ofﬁcers to stop the restraint process to inquire about the subject's
medical history (Pilant, 1996)

Deaths during restraint can involve interference with the victim's ability to
breathe, usually by chest or neck compression. Restraint of a subject which
employs methods that interfere with the muscular mechanics of breathing, can be

considered the use of potentially lethal force. Such restraint methods include the

34

arm bar hold, squeezing the neck with the hand(s), and kneeling or sitting on the
upper back or chest (Wutzer, 1995). Additionally some researchers suggest that
there is a direct connection between a subject's wild behavior and a greatly
increased risk of death. This increased risk of death exists regardless of the type
of restraint and the level of force used (Reay, 1993).

One of the potential lethal arrest complications when using physical
restraint is restraint stress resulting in sudden death. Similar to excited delirium,
death can occur from fatal cardiac arrhythmia, which is believed to be a result of
an individual’s perception of over whelming stress, the physical struggle against
the restraint, and the release of hormones that may cause ventricular arrhythmia
(Ross, 1997). In addition to restraint stress, other causes of death may include
asphyxiation due to respiratory muscle fatigue and restraint asphyxia.
Asphyxiation due to respiratory muscle fatigue can occur as a result of extreme
exertion and struggle against restraints (Stratton et al., 1995). Restraint asphyxia
may occur when a suspect’s chest is compressed after being forced to the
ground during the arrest process. When ofﬁcers apply their own body weight to
the suspect’s chest area to obtain control, the subject may be unable to expand

or contract his or her chest freely during the breathing process (Reay, 1998).

Investigating Deaths ln-custody
Investigation
When a subject dies while in custody, police agencies must provide

comprehensive written and photographic documentation of the prisoner's death

35

for the proper disposition of administrative, public, and legal issues and questions
that will most likely arise (Luke & Reay, 1992). Answers to such questions may
help to establish a timeline of events surrounding the death. Ofﬁcers should
carefully document the type and amount of forced used, the behaviors and
medical condition (if known) of the subject, the type of restraint equipment
utilized, and the nature of the transport and monitoring procedures employed. If
the subject is transported to a medical facility by the arresting ofﬁcer(s), the
ofﬁcer(s) need to communicate to the medical personnel the nature of the arrest,
the subject's behaviors, the restraint methods used, and the nature of the
transport (Ross, 1997).

A detailed description of events that led to and occurred during the arrest
and restraint of the subject is essential (Frost & Hanzlick, 1988). The ofﬁcer’s
report should include explicit witness statements about the subject's behavior,
noting any unusual physical respiratory signs, such as vocalizing, gurgling,
gaSping, and difﬁculty breathing, as well as complete circumstantial information
about the arrest, take-down, and restraint methods used (Granﬁeld et al., 1994).
The report should also indicate if the sudden death of the subject occurred
without successful resuscitation despite equipped and trained ALS personnel
witnessing the cardiopulmonary arrests and attempting resuscitation, and if the
death occurred during transport by medical personnel (Reay, 1996). Supervisors
should also review arrest and transport documentation to ensure the proper

adherence to policy (Ross, 1997).

36

According to Reay (1998), when these types of death do occur, questions
are frequently asked. These questions usually include the following: ( 1) Was
unnecessary force used during arrest? (2) Was the person physically abused by
the ofﬁcers? (3) Were unlawful acts of violence or misconduct committed by the
ofﬁcers? (4) Was serious and obvious illness in the person ignored or overlooked
by the police? (5) Were legitimate complaints minimized or disregarded? (6) Was
medical attention provided to the subject when needed for injuries or illness? (7)
Were there any steps taken to prevent the occurrence of the incident? (8) Did the
authorities monitor the subject sufﬁciently? And (9) were every reasonable
means taken to protect the safety and welfare of the subject from any form of
self-directed violence?

Law enforcement agencies should release as much information as
possible, because to withhold information may only serve to create an
atmosphere of suspicion. In cases where the cause of death has been clearly
established, it serves no purpose to conceal information from the public.
However, when information is a mixture of hearsay and fact, it may be wise to
avoid releasing details concerning the death until such time as the facts are

clearly established (Reay, 1998).

Autopsy

The autopsy is considered by some to be one of the most important
aspects of the investigation (Wutzer, 1995). The purpose of the autopsy is to

establish as precisely as possible the cause of death (Reay, 1998). Pathologists

37

generally require three things to make an assessment for establishing the cause
of death: (1) A complete forensic autopsy, (2) a toxicological analysis of body
ﬂuids, and (3) a detailed history of the events surrounding the subject's death
(Reay, 1996). An autopsy can reveal whether a catastrophic natural disease,
such as a heart attack or stroke, caused the death. Research suggests that a
complete toxicological examination should be included with the autopsy when a
sudden in-custody occurs. Toxicological analysis of body ﬂuids for the presence
of drugs and alcohol can provide important information when determining the
cause of death (Reay et al., 1992). Furthermore, it is not uncommon to ﬁnd the
presence of alcohol, street, and therapeutic drugs in persons who die in-custody.
When the use of alcohol was viewed as a crime, alcoholism was reported
as being a major factor in sudden deaths (Reay, 1998). Street drugs such as
cocaine, methamphetamine and therapeutic drugs used to treat mental disorders
(e.g., manic depression and psychosis), or medical conditions may be
responsible for sudden deaths (Reay, 1998). Currently, there appears to be little,
if any, scientiﬁc evidence that exists for the designation of lethal and non-lethal
cocaine and or amphetamine blood levels. Lethal levels of cocaine and
amphetamine currently have not been established because of the wide range of
levels found in individuals with minimal and severe toxicity. Blood levels of these
drugs in individuals at autopsy may range from nearly zero to extraordinarily high
levels. Toxicity from cocaine or amphetamine may have been the sole cause of
death in individuals with both minimal and severely high blood levels (Stratton,

1995).

38

Additionally, on the average, 1 of every 10 cocaine-related deaths is
believed to be due to agitated delirium (Kareh & Wetli, 1995). This is found in
areas where cocaine use is high. In areas where cocaine-related deaths are less
frequent, so are deaths attributed to excited delirium, and it is important to note
that when considering blood levels of drugs, many of the recent deaths attributed
to positional asphyxia appear to be based on early cases studies and articles.
Current research suggests that the amounts of blood drug levels do not have to
be lethal and drugs need not be present in the blood for an in-custody death to
occur (Reay, 1993). Thus, just knowing the blood drug levels appears not to be

enough to determine if the drug itself was the cause of death.

Liability

When a wrongful sudden in-custody death occurs as a result of an action
taken by law enforcement ofﬁcers, citizens my seek redress though the legal
system. Citizens seeking redress for wrongful sudden in-custody death can
successfully sue police ofﬁcers under 42 U.S.C. 1983. They can sue if they can
show that the ofﬁcer was acting under the color of state law, if the alleged
violation was of a constitutional or federally protected right, and the alleged
violation reached a constitutional level (Kappeler, 1993).

In cases involving sudden in-custody death and restraint, plaintiffs
generally allege that the hog-tie restraint position constitutes excessive force.
Plaintiffs may argue that hog-tying, the prone position, keeping weight on the

body after the subject has been restrained and failure to render CPR constitutes

39

excessive force and that such actions cause positional asphyxia and death. They
may also claim that the ofﬁcers were "deliberately indifferent" for failing to closely
monitored the subject, failing to place the subject on his or her side to reduce
dangers from restraint positions, and failing to provide cardiopulmonary
resuscitation (CPR) when needed (Price v. County of San Diego, 1998).
Furthermore, agencies and their perspective cities can be held deliberately
indifferent to the danger that suspects under the inﬂuence of drugs could die from
positional asphyxia if handcuffed in a prone position (Animashaun v. O'Donnell,
1995).

Agencies can also be charged under 42 U.S.C. 1983 with violating the
Fourth and Fourteenth Amendment right to be free from excessive force. All
claims that law enforcement ofﬁcers have used excessive force in the course of
an arrest and restraint must be analyzed under the Fourth Amendment and its
"reasonableness" standard. Under the Fourth Amendment, peace ofﬁcers must
use only an amount of force that is reasonable in light of all the surrounding
circumstances (Price v. County of San Diegg, 1998).

Additionally, plaintiffs may allege a cause of action under 42 U.S.C. 1983
against the agency and county, relying on the theory of municipal liability as
articulated in Monell v. New York City Department of Social Services (1978). To
hold the agency and county liable for constitutional wrongs inﬂicted by its ofﬁcers,
plaintiffs must prove that a policy or custom existed. The policy or custom
exhibited deliberate indifference to the rights of people with whom the ofﬁcers

could come into contact, and that the policy was the moving force behind the

40

constitutional violation in question (Price v. County of San Dieqo, 1998). Plaintiffs
may also allege state law causes of action against ofﬁcers for wrongful death,
assault, battery, and negligence. However, absent a constitutional injury,
plaintiffs will not have a claim of liability under 42 U.S.C. 1983.

In Estate of Phillips v. City of Milwaukee (1997), the court held that there
was not enough information on positional asphyxia to defeat qualiﬁed immunity
or sustain a failure-to-train claim. Also, ofﬁcer’s actions are determined to
reasonable provided that they only apply the minimum weight necessary to

control the subject while he is being restrained. Furthermore, in Price v. County

 

of San Diego ( 1998) the court has determined there is not enough evidence that
the hog-tie position interferes with breathing to the point that is causes positional
asphyxia and there is no evidence that the hog-tie restraint position leads to
cardiac arrest. Applying the hog-tie restraint to an individual who is violently
resisting arrest is not, in and of itself, excessive force. Furthermore, for
individuals who are in a state of methamphetamine or cocaine induced toxic
delirium, death is more consistent with toxic delirium secondary to drug abuse.
The amount of information available today regarding positional asphyxia
virtually ensures that cases are likely to survive summary judgment motions and
proceed to trial. These cases are difﬁcult to defend against because jurors are
likely to be sympathetic to the argument that, no matter how violently the
deceased was acting prior to being restrained, he or she should have been

restrained in a manner that would not have kill him or her (Reak, et al., 1998).

41

Training

The importance of law enforcement training and the profound effect it can
have on individual ofﬁcer performance cannot be over emphasized (Perry &
McDonough, 1995). Law enforcement trainers should develop a block of training
which identiﬁes the medical risk factors associated with sudden custodial death,
appropriate force techniques, authorized restraint equipment, and monitoring
procedures (Ross, 1997). Trainers should instruct how to restrain someone
appropriately, not forbid the use of restraints (Postill & Rowan, 1998).

Restraint training should teach all of the force options available to the
ofﬁcers including the standards ofﬁcers are held to when using force and how to
appropriately document the use of the force when force is used. The training
program should include the characteristics of a person who is a prime subject for
possible in-custody death, such as a person who is in the midst of excited
delirium (Gallagher, 1996).

Training should cover that during the process of arrest ofﬁcers should try
to subdue subjects as quickly as possible to reduce confrontation time,
expenditure of muscle energy and the chance of injury to themselves and the
subject. As soon as the subject is restrained and when actually safe, any body
weight being applied to the subject should be removed. Current research
suggests that the prisoner, if possible, should be placed in an upright position or
turned on his or her side. Ofﬁcers should attempt to get the subject talking and
ascertain if he or she has any medical problems or respiratory diseases (Ross,

1997).

42

The ofﬁcers should continuously monitor the subject. This should include
eliciting verbal responses to the ofﬁcer's questions, and if necessary immediate
medical attention must be provided. Ofﬁcers should understand that pain
compliance would probably not be effective against mental patients who are
acutely psychotic or drug abusers who are in the acutely agitated, toxic
psychosis state. Training should include methods to calm and contain such
persons, and how to recognition situations when calming techniques may be
more effective than pain compliance (Bugreen et al., 1992).

Instructors should stress awareness and vigilance when teaching ofﬁcers
the proper use of hog-tie restraint. Whenever the hog-tie restraint is employed,
ofﬁcers should determine whether the subject has used drugs or suffered from
cardiac or respiratory diseases (Perry & McDonough, 1995). They should learn
how adverse positions may affect a subject’s breathing and how to recognize
signs of respiratory distress (Kareh & Wetli, 1996). The use of restraints to punish
prisoners for misconduct is inappropriate and should not be tolerated (Postill &
Rowan, 1998).

Additionally, ofﬁcers should not automatically put suspects in four-point
restraints or hog-tie them. There should be some use of a force or restraint
continuum. Training should include identiﬁcation of those individuals at risk for
sudden death, recognition of subjects exhibiting the symptoms of cocaine
psychosis or similar drug-induced syndromes, and appropriate ﬁrst aid for such
high risk individuals. Ofﬁcers should also have knowledge of the effective force

options to use against high risk individuals (“Sudden in-custody death,” 1996). If

43

prone positioning is required, subjects should be closely and continuously
monitored (Perry & McDonough, 1995). Furthermore, every agency should have
an up to date “use of restraints" policy. The policy should state clearly when and

how to properly use restraints (Postill & Rowan, 1998).

Policy Development

Policy development should include a wide range of reasonable force
options according to a force continuum and should authorize the proper restraint
equipment to be used (Postill & Rowan, 1998). When addressing in-custody
death issues, policies should identify some of the basic signs or symptoms
subjects generally display prior to cardiac arrest or sudden death (see Tables 2,
3 and 4). Policies should also give some directive action when these signs or
symptoms are observed while acknowledging that it is impossible to identify all
possible signs a person can give prior to sudden death while in custody or while
being apprehended.

Vlﬁthdrawal from alcohol and alcohol-related illness appears to account for
a signiﬁcant numbers of in-custody deaths (Frost & Hanzlick, 1988). Persons
recently placed in-custody should be evaluated for intoxication or alcohol
dependency. They should be closely observed for symptoms of alcohol
withdrawal. Research suggests that death may result from alcohol poisoning or
postural asphyxia clue to alcohol-induced unconsciousness (Perry & McDonough,

1995). Additionally, persons may appear to be intoxicated when, in fact, they are

44

suffering from head trauma (Frost & Hanzlick, 1988). However, historical
information and physical examination may rule out trauma.

Death may result from an excessive ingestion of drugs prior to arrest.
Persons with a history of such activity should be questioned, and if necessary,
treated for such conditions. Also, combativeness may indicate the presence of
certain drugs such as cocaine, which may induce a paranoid violent aggressive
behavior that proceeds to an exhaustive mania and death (Wutzer, 1995). Violent
behavior may indicate an intoxication that requires emergency treatment.

Within the ﬁrst few days of incarceration many custody deaths seem to
occur as a result of suicides and drug intoxication or withdrawal. Many violent in-
custody deaths involve violence against one's self (suicide) (Frost & Hanzlick,
1988). Great care should be taken to detect and monitor those with self-
destructive tendencies. Research suggests that arrests for more serious offenses
such as assault, rape and murder may indicate a higher risk for suicide (Frost &
Hanzlick, 1988). Ofﬁcials should be aware of this high-risk period for such
deaths. Furthermore, persons who are physically restrained should not be left
unattended. Postural restraints may predispose the prisoner to positional
asphyxia and death (Ross, 1997).

Administrators should take a proactive approach to reduce such deaths.
They should rethink and revise policies to help ofﬁcers assess any "special
needs" prisoners may have. They should provide training in risk factor
recognition, control and restraint techniques, and provide restraint equipment that

will help to avert asphyxia related deaths. Additionally, administrators should

45

examine the actions of their employees and establish restraint policies that will
withstand court and citizen review if they want to avoid restraint liability litigation

(Ross, 1997).

Transportation of Prisoners

During prisoner transport, ofﬁcers should ensure that the restrained
prisoner does not fall facedown in the back of the squad car or become
positioned in a way as to cause positional asphyxia (e.g., neck hyperﬂexed).
Instructors should stress vigilance in monitoring the subject's condition.
Restrained subjects might not exhibit any clear symptoms before they simply
stop breathing. Generally it takes several minutes for signiﬁcant hypoxia to occur,
but it can happen more quickly if the subject has been violently active and is
already out of breath (Kareh & Wetli, 1996). If the subject experiences extreme
difﬁculty breathing or stops breathing altogether, ofﬁcers should take at least
some immediate minimal steps for resuscitation, such as changing the subject's
body position, and obtaining medical care. CPR should not be mandated
because in doing so this may expose ofﬁcers to blood born pathogens and highly
contagious diseases.

According to Burgreen et al. (1992) two ofﬁcers should transport subjects
determined to be at high risk and one ofﬁcer should be assigned to constantly
monitor the prisoner watching for signs of breathing difﬁculties, changes in skin
color or level of consciousness. If these prisoners are to be transported, they

should be constantly monitored while enroute. The prisoner should be

46

transported in an upright position secured with the seatbelt provided, if doing so
does not expose the ofﬁcers to great risk. Some policies suggest that when
transporting at night, the interior light of the vehicle should be illuminated so the
subject can be monitored. However, this may expose the ofﬁcers to unnecessary
risk from snipers in high crime areas and may impair night vision while driving. A
better procedure would be to have the one ofﬁcer assigned to monitor the
prisoner do so with a ﬂashlight when needed.

It is important to understand how preexisting risk factors, combined with
the subject's body position when subdued or in transit, can compound the risk of
sudden death (Perry & McDonough, 1995). Ofﬁcers need to be alert to the
possibility that when enroute to the jail, the victim may slip down and become
wedged between the front and backseats. This position can contribute to
positional asphyxia or sudden death. Ofﬁcers should not assume or calm a
prisoner is simply asleep or harmlessly intoxicated.

Some police departments have policies requiring ofﬁcers to roll
handcuffed suspects onto their sides or sit them upright as soon as possible.
However, it may not be practical in all cases to turn the suspect over prior to
being placed in the back seat of a police car or on the gurney because of
concern that the suspect would injure himself or herself or the ofﬁcers.
Paramedics from the ambulance service contend that there is nothing wrong
about transporting suspects facedown. Some feel that it is the safest way to
transport combative patients and police prisoners, and that they transport many

people that way every weekend (Reak et al., 1998).

47

Prisoner Care

Regardless of the type of activity law enforcement ofﬁcers are engaged in,
the law requires an ofﬁcer to act or behave toward other individuals in a certain,
deﬁnable way. The manner in which the individual must act or behave is called
the standard of care and may be established by local custom, statutes,
ordinances, administrative regulations, case law, and professional or institutional
standards. The standard of care can be deﬁned as how a reasonable prudent
person with similar training and experience will act under similar circumstances,
with similar equipment, and in the same place (Emmency Care and
Transportation, 1987). Law enforcement personnel should familiarize themselves
with the particular legal standards that may exist in their jurisdiction to avoid
potential legal problems that may occur when the standard of care is not met.

When an ofﬁcer fails to provide medical treatment to an ill or injured
prisoner, causing further injury or harm to that prisoner, the courts may ﬁnd the
ofﬁcer negligent and in violation of the standard of care (Frost & Hanzlick, 1988).
In situations where there is high risk for sudden in-custody deaths to occur, it is
important to development the understanding that it is the ofﬁcer's responsibility to
ensure the prisoner is breathing adequately (Kareh & Wetli, 1996). Once the
individual is controlled and handcuffed, the ofﬁcer should monitor the person’s
color, breathing, and level of consciousness. If any abnormalities are observed,
or if there is any doubt regarding the prisoner's condition, ofﬁcers should
immediately transport the individual to the nearest emergency medical facility or

paramedics should be called to the scene (Frost & Hanzlick, 1988).

48

According to Burgreen et al. (1992), the decision to transport the prisoner
by police vehicle or to call paramedics to the scene should be based on the
ofﬁcers judgement. The judgement should be based on which option will provide
the fastest access to advanced life support and professional medical care given
the speciﬁc circumstances of the incident. High risk maximally restrained
subjects who are in need of medical attention (e.g., respiratory distress, loss of
consciousness) should be transported to a hospital by ALS personnel and

evaluated by a physician.

49

Chapter 3

METHODOLOGY

This chapter outlines the methodology used in the thesis.) This includes (1)
population and sample selected, (2) the development of the instrument, (3) how
the instrument was utilized, (4) how the data were analyzed for similarities and

differences, and (5) how the respondents responded to the survey.

Universe of Law Enforcement Agencies

The purpose of this thesis is to determine the custody related policies of
large law enforcement agencies in the United States dealing with the issues of
sudden death, prisoner restraint and positional asphyxia. A universe was
established from data provided by the Bureau of Justice Statistics (BJS)
Directory of Law Enforcement Agencies.

To determine the population of law enforcement agencies in the United
States, BJS sponsored a census of the nation’s state and local law enforcement
agencies. The results constituted at best an approximation of the total number of
these agencies. A more accurate universe (an actual count) would have been too
difﬁcult to validate because agencies are continually being created, merged and
disbanded (Bureau of Justice Statistics, 1998).

The universe of law enforcement agencies in the United States consisted
of approximately 18,769 departments employing at least one full-time or part-time

sworn ofﬁcer with general arrest powers as of 1996. There are 13,578 general-

50

purpose local police departments, 3,088 sheriffs’ departments and ofﬁcers, 49
primary state law enforcement agencies, 1,316 state and local agencies, and 738
county constables in Texas included in this population. Overall, state and local
law enforcement agencies employed 663,535 full-time sworn ofﬁcers (Bureau of

Justice Statistics, 1998).

Sampling Frame

The initial sampling frame consisted of 153 state and local law
enforcement agencies employing 499 or more full-time sworn ofﬁcers. The
largest agency employed 36,813 sworn ofﬁcers. The sample frame included 69
municipal police agencies, 37 sheriff’s departments, 32 state police agencies, 11
county police departments and 4 special police agencies. The 153 law
enforcement agencies accounted for approximately 2% of all the agencies and
employed 261,337 or 39.4% of all full-time the sworn personnel.

Agencies with 499 or more full-time sworn personnel were selected
because the majority of agencies, some 10,696 in all, employ less than 10 sworn
personnel. Also, this sampling frame is thought to contain the largest police
departments in the United States. Thus, their policies and procedure will most
likely affect a large portion of the citizens in the United States. Residents of the
larger cities live in the jurisdiction of one of these agencies and more citizens are
affected by their policies. Suburban or rural residents are most likely living in
areas where their police departments are inﬂuenced by the larger agency policy

(Kennedy, Homant & Kennedy, 1992).

51

The Instrument

The instrument developed is a questionnaire designed to elicit related
policy information concerning prisoner restraint, prisoner transportation, hog-tying
and positional asphyxia (see Appendix A for original questionnaire). The
questionnaire was sent to all 153 agencies. The questionnaire included 27
questions developed for the survey that were written to elicit a yes or no
response. In addition, a comment section was provided. The purpose of the letter
was to explain the reason for the study to the respondents in each department.
The instrument was sent with a cover letter (see Appendix B for original cover
letter) indicating that the results of this research would be very helpful for law
enforcement in general in its effort to improve policies and procedures
concerning prisoner restraint and positional asphyxia. The letter further explained
the study by (1) clarifying its purpose and goals, and (2) requesting a return of
the questionnaire by appealing to the civic duties of the law enforcement

agencies that would receive it.

Distribution of the Instrument

The questionnaire and instructions for its completion were ﬁrst distributed
by mail to the 153 respondents on January 29‘“, 1999. Each of the 153 agencies
was sent a complete questionnaire package including the cover letter as well as
a stamped self-addressed envelope. There was no deadline for returning the
questionnaire; however, the respondents were asked to complete and return the

questionnaire as soon as possible. On January 15, 1999 a follow-up letter and

52

another complete questionnaire package were sent to the remaining agencies
that had not returned the questionnaires (see Appendix C for follow up letter) for
the purpose of increasing the response rate (Maxﬁeld & Babble, 1995). The
respondents were asked to complete and return the survey as soon as possible.
The experimental study design and protocol were reviewed and approved by the

Human Subjects Committee of Michigan State University.

Data Analysis

In order to test the hypotheses and determine if any relationships exist
between the variables, frequency tables, crosstabulations and Chi Square values
are used. Frequency tables are generated to determine the response rates to the
survey questionnaire. Crosstabulations are used to summarize the relationship
between the independent and the dependent variables, and Chi-Square
signiﬁcant values are used to determine if the variables are independent or
related and whether or not the null hypotheses were rejected (see pages 14-16).
The SPSS program (Statistical Pack for Social Sciences) is used for analyses

(Norusis, 1997).

Survey Response

Of the 153 agencies that were contacted, 120 (78.4%) responded in some
way to the survey questionnaire. Of the 118 (77.1%) that completed and returned
the survey, 35 (22.9% ) did not return the survey. This response rate is

considered very good and there is reduced concern for signiﬁcant non-response

53

bias (Maxﬁeld & Babble, 1994). Of the 35 agencies that did not return the survey,
33 (21.6%) did not respond and gave no explanation, 1 (.7%) refused because
they were currently involved in litigation regarding sudden in-custody death, and
1 (.7%) refused because they believed the survey subject information was too

sensitive (see Table 5).

 

Table 5.

Response Rate - Survey

 

Frequency Percent
Filled out — returned 118 77.1
Did not return
No explanation 33 21.6
Too sensitive 1 .7
Under litigation 1 .7
Total 153 100

 

54

 

Chapter 4

FINDINGS

This chapter will ﬁrst examine the responses to each of the following
questions: (1) Does your policy prohibit the transportation of prisoners in the
prone position? (2) Does your policy prohibit the hog-tying of prisoners? (3) Are

your ﬁeld ofﬁcers trained to recognize positional asphyxia? And (4) has your

VVLV‘

agency had any deaths attributed to positional asphyxia within the last ﬁve

years?

 

 

rm u _- aura“ "

This chapter will also examine each of the three hypotheses. The
crosstabulation method is used to summarize the relationship between the
variables using the Chi-Square signiﬁcant value to test the null hypotheses to
determine if the variables are related. If the variables are found to be signiﬁcantly
related, at least to the .05 level, the phi coefﬁcient will be introduced to indicate
the strength of the relationship between the variables being tested. Additionally,

some asumptions will be drawn regarding these relationships.

Responses To The Survey Questions
(1) Does your policy prohibit the transportation of prisoners in the prone position?
Table 6 indicates the agency responses to the survey question asking
whether or not their policies prohibit the transportation of prisoners in the prone
position. Of the 118 agencies that responded to the survey question, 49 (41.5%)

prohibited the transportation of prisoners in the prone position by policy, and 64

55

(53.8%) did not prohibit the transportation of prisoners in the prone position. Five
(4.7%) did not have a prisoner transportation policy. Thus, it maybe assumed
that 69 (58.5%) did not prohibit the transportation of prisoners in the prone

position.

 

Table 6.

Response Rate - Prohibit Transportation Prone

 

Frequency Percent
Yes 49 41.5
No 64 53.8
Have no policy 5 4.7
Total 1 18 100

 

(2) Does your policy prohibit the hog-tying of prisoner?

Table 7 indicates the agency responses to the survey question asking
whether or not their policies prohibited the hog-tying of prisoners. Of the 117
agencies that responded to the survey question, 43 (36.8%) prohibited the hog-
tying of prisoners by policy, and 47 (39.9%) did not prohibit hog-tying. Twenty-
seven (23.3%) did not have a policy that addressed hog-tying. Thus, it maybe

assumed that 74 ( 63.2%) did not prohibit the hog-tying of prisoners.

56

 

Table 7.

Response Rate - Prohibit Hog-tying

 

Frequency
Yes 43
No 47
Have no policy 27
Total 1 17

Percent

36.8

39.9

23.3

100

 

(3) Are your ﬁeld ofﬁcers trained to recogni_ze positional asphyxia?

Table 8 indicates the agency responses to the survey question asking

whether or not they had ﬁeld ofﬁcers trained to recognize positional. Of the

hundred 117 agencies that responded to the survey question, 94 (80.3%) had

ofﬁcers trained to recognize positional asphyxia, and 19 (14.7%) did not have

ﬁeld ofﬁcers trained to recognize positional asphyxia. Four (4.9%) were unaware

of positional asphyxia. Thus, it was maybe assumed that 23 (19.6%) did not have

ﬁeld ofﬁcers trained to recognize positional asphyxia.

57

 

 

Table 8.

Response Rate - Field Ofﬁcers Trained To Recognize

Positional Asphyxia

 

Frequency Percent
Yes 94 80.3
No 19 14.7
Unaware 4 4.9
Total 1 17 100

 

(4) Has your agency had any deaths attributed to positional asphyxia within the
last ﬁve years?

Table 9 indicates the agency responses to the survey question asking
whether or not agencies had any deaths attributed to positional asphyxia in the
last 5 years. Of the 118 agencies that responded to the survey question, 22
(18.7%) had in-custody deaths attributed to positional asphyxia, and 82 (68.8%)
had no such deaths. Eleven (9.6%) did not know of any such deaths, and 3
(2.9%) were unaware of positional asphyxia. Thus, It maybe assumed that 96

(81.3%) had no deaths attributed to positional asphyxia in the last 5 years.

58

. .... ”II

 

1r.

 

Table 9.
Response Rate - Deaths Attributed to Positional

Asphyxia Last 5 Years

 

Frequency Percent
Yes 22 18.7
No 82 68.8
Unknown 1 1 9.6
Unaware 3 2.9
Total 118 100

 

Tables 6 through 9 reveals that most agencies did not prohibit the
transportation of prisoners in the prone position, did not prohibit the hog-tying of
prisoners, and had ofﬁcers trained to recognize positional asphyxia. Additionally,
most agencies did not report deaths attributed to positional asphyxia in the last 5

years.

Hypothesis Testing
Hypothesis 1
M
There is no signiﬁcant relationship between agencies that prohibit the
transportation of prisoners in the prone position and deaths that could be

attributed to positional asphyxia.

59

 

Alternate
There is a signiﬁcant relationship between agencies that prohibit the
transportation of prisoners in the prone position and deaths that could be

attributed to positional asphyxia.

Table 10 indicates the relationship between those agencies that have
policies that prohibit the transportation of prisoners in the prone position and
reported deaths attributed to positional asphyxia in the last ﬁve years. Of the 49
agencies that prohibited the transportation of prisoners in the prone position,
24.5% reported deaths attributed to positional asphyxia, and 75.5% reported no
deaths. Of the 69 agencies that did not prohibit the transportation of prisoners in
the prone position, 14.5% reported deaths attributed to positional asphyxia, and
85.5% reported no deaths. Thus, a greater number of agencies (24.5%) that
prohibited the transportation of prisoners in the prone position were most likely to
report more deaths attributed to positional asphyxia than those agencies (14.5%)
that did not prohibit such transport.

Table 10 also shows the Chi Square value used to determine whether
having a policy that prohibits the transporting prisoners in the prone position and
having any deaths attributed to positional asphyxia are related. The Chi-Square
value of 1.88 with signiﬁcance of .169 is greater than the critical value of .05. The
null hypothesis that there is no signiﬁcant relationship between agencies that
have policies that prohibited the transportation of prisoners in the prone position

and having any deaths attributed to positional asphyxia is not rejected. There

60

appears to be no difference in reported deaths due to positional asphyxia
between agencies that prohibited the transportation of prisoner in the prone

position and those agencies that did not prohibit such transport.

 

Table 10.
Prohibit Transport Prone by Deaths Attributed to Positional Asphyxia

Last 5 Years

 

Yes No Total X 2 Sig. ¢

1.88 .169 .126

Deaths

Yes 12 24.5 10 14.5 22 18.6
No 37 75.5 59 85.5 96 81.4
Total 49 100 69 100 118 100

 

Note. n = number of agencies; % of agencies; x2 = Chi-Square; (Sig.) =

signiﬁcant value of Chi-Square; ¢ = Phi Coefﬁcient; * critical value p = .05

Hypothesis 2
N_u_||
There is no signiﬁcant relationship between agencies that prohibit hog-

tying and deaths that could be attributed to positional asphyxia.

61

r,
I
j!
.3
.i

 

Alternate
There is a signiﬁcant relationship between agencies that prohibit hog-tying

and deaths that could be attributed to positional asphyxia.

Table 11 indicates the relationship between agencies that have policies
that prohibit the hog-tying of prisoners and reported deaths attributed to
positional asphyxia in the last 5 years. Of the 43 agencies that prohibited hog-
tying, 27.9% reported deaths, and 72.1% reported no deaths. Of the 74 agencies

that did not prohibit hog-tying, 12.2 % reported deaths and 87.7% reported no

 

deaths. .5.

 

Table 11.

Prohibit Hog-tying by Deaths Attributed to Positional Asphyxia Last 5 Years

 

Yes No Total x2 Sig. q)
n % n % n %

4.5 .032 .198

Deaths

Yes 12 27.9 9 12.2 21 17.9
No 31 72.1 65 87.8 96 82.1
Total 43 100 74 100 117 100

 

Note. n = number of agencies; % of agencies; x2 = Chi-Square; (Sig) =

signiﬁcant value of Chi-Square; ¢ = Phi Coefﬁcient; * critical value p = .05

62

Table 11 also shows the Chi-Square value used to determine whether
having policies that prohibit the hog-tying of prisoners and reported deaths
attributed to positional asphyxia are related. The Chi-Square value of 4.5 with
signiﬁcance of .032 is less than the critical value of .05. Therefore, the null
hypothesis that here is no signiﬁcant relationship between agencies that have
policies that prohibit the hog-tying of prisoners and reported deaths attributed to
positional asphyxia is rejected. There appears to be a signiﬁcant relationship
between agencies that have a policy that prohibits the hog-tying of prisoners and
deaths attributed to positional asphyxia. However, this relationship is very weak

(4: =.198) and not in the expected direction. It is expected that fewer agencies

that prohibit the hog-tying of prisoners would report deaths attributed to positional
asphyxia. However, a larger number of agencies that prohibited the hog-tying of
prisoners reported deaths attributed to positional asphyxia then those agencies

that did not prohibit hog-tying.

Hypothesis 3

MI

There is no signiﬁcant relationship between agencies that train their ﬁeld
ofﬁcers to recognize positional asphyxia and deaths that could be attributed to

positional asphyxia.

63

Alternate
There is a signiﬁcant relationship between agencies that train their ﬁeld
ofﬁcers to recognize positional asphyxia and deaths that could be attributed to

positional asphyxia.

Table 12 indicates the relationship between those agencies that have ﬁeld
ofﬁcers trained to recognize positional asphyxia and agencies that reported
deaths attributed to positional asphyxia. Of the 94 agencies that had ﬁeld ofﬁcers
trained to recognize positional asphyxia, 22.3% reported having deaths attributed
to positional asphyxia, and 77.7% reported having no deaths. Of the 23 agencies
that did not have ﬁeld ofﬁcers trained to recognize positional asphyxia, 4.3%
reported deaths attributed to positional asphyxia and 95.7% reported no deaths.

Table 12 also shows the Chi Square value used to determine whether
having ﬁeld ofﬁcers trained to recognize positional asphyxia and reported deaths
attributed to positional asphyxia are related. The Chi-Square value of 3.9 is
signiﬁcant at .048 or less. Therefore, the null hypothesis that there is no
signiﬁcant relationship between having ﬁeld ofﬁcers trained to recognize
positional asphyxia and having any deaths attributed to positional asphyxia is
rejected. There appears to be a signiﬁcant relationship between agencies that
have ﬁeld ofﬁcers trained to recognize positional asphyxia and deaths attributed

to positional asphyxia. However, this relationship is weak ((1) =.183) and not in the

expected direction. It is expected that fewer agencies that have ﬁeld ofﬁcers

trained to recognize positional asphyxia would report deaths attributed to

64

positional asphyxia. However, a larger number of agencies that had ﬁeld ofﬁcers
trained to recognize positional asphyxia reported deaths attributed to positional
asphyxia then those agencies that did not have ofﬁcers trained to recognize

positional asphyxia.

 

Table 12.
Field Ofﬁcers Trained to Recognize Positional Asphyxia by Deaths

Attributed to Positional Asphyxia Last 5 Years

 

Yes No Total x2 Sig. q)
n % n % n %

3.9 .048 .183

Deaths

Yes 21 22.3 1 4.3 22 18.8
No 73 77.7 22 95.7 95 81.2
Total 94 100 23 100 1 17 100

 

Note. n = number of agencies; % of agencies; x2 = Chi-Square; (Sig) =

signiﬁcant value of Chi-Square; 4) = Phi Coefﬁcient; * critical value p = .05

65

Chapter 5

CONCLUSION

This chapter will summarize several of the theories regarding positional
asphyxia and identify some of the issues that these theories do not address. This
chapter will also discuss new research conclusions, the ﬁndings of this research
and other possible causes of sudden in-custody death. Additionally, suggestions
are made to aid law enforcement personnel in developing methods to reduce the
occurrence of positional asphyxia related and sudden in-custody deaths.

A large amount of research indicates positional asphyxia has been
incorrectly identiﬁed as the primary cause of death for those persons who die in-
custody while hog-tied or handcuffed and placed in a prone position. In many
such instances law enforcement agencies and ofﬁcers may have been unjustly
held liable. Some researchers suggest that sudden in-custody death occurs as
result of positional asphyxia caused by placing a subject in the prone position or
hog-tying a subject. They propose that the hog-tie restraint method and the prone
position interfere with respiration, creating an oxygen deﬁcit resulting in
asphyxiation and death. They further suggest that in all cases of positional
asphyxia the subjects are not able to correct themselves from the harmful
position (Reay et al., 1992). However, these theories do not explain why subjects
who become unconscious still die after immediately being repositioned. They do

not explain why sudden death occurs when immediate medical attention is

66

rendered by medical personnel either on scene or at the hospital. And, they do
not explain why sudden death occurs when subjects are not restrained.

New research concludes that hog-tying has minor effects on the breathing
process, and does not signiﬁcantly affect blood oxygen or carbon dioxide levels
(Price v. County of San Diego. 1998). Factors other than the hog-tie position
appear to be more important determinants for sudden in-custody deaths. These
factors include illicit drug use, physiologic stress, hyperactivity, hyperthermia,
catechol (adrenal Hormone) hyperstimulation and trauma from struggle (Chan et
al., 1997; Chan Vilke, & Neuman, 1998). The hog-tie restraint position by itself
has been determined not cause respiratory compromise to the point of
asphyxiation and death, and applying the hog-tie restraint prone position to
individuals who are violently resisting arrest is not the use of excessive force
(Price v. County of San Diego, 1998).

This research found that a relationship exists between agencies that
prohibit hog-tying and deaths attributed to positional asphyxia. A larger number
of agencies that prohibit the hog-tying of prisoners reported deaths attributed to
positional asphyxia in the last 5 years. Also, a larger number of agencies that
have ﬁeld ofﬁcers trained to recognize positional asphyxia reported deaths
attributed to positional asphyxia in the last 5 years. These ﬁndings suggest that
prohibiting hog-tying is positively associated with deaths attributed to positional
asphyxia, and training ﬁeld ofﬁcers to recognize positional asphyxia is positively

associated with deaths attributed to positional asphyxia.

67

However, this is counter-intuitive. It is expected that fewer agencies that
prohibit hog-tying and/or that have ﬁeld ofﬁcers trained to recognize positional
asphyxia would report deaths attributed to positional asphyxia. One possible
explanation for these ﬁndings is that the deaths occurred before any policy
changes; before hog-tying was prohibited and/or ﬁeld ofﬁcers were trained.
Another possible explanation is that the deaths occurred regardless of the policy
changes. In other words, it makes no difference whether agencies prohibit hog-
tying or train their ﬁeld ofﬁcers to recognize positional asphyxia, the deaths would
have still occurred. Thus, the deaths are not a result of positional asphyxia, they
are a result of other causes and are being incorrectly identiﬁed.

Unfortunately the data due not allow the investigation of temporal
sequence of events. In other words, it is unclear if the deaths came before or
after the implementation of the policies. The reason for this is because only one
question is time bounded. What can be concluded from this research is that the
majority of agencies, 81.3% had no deaths attributed to positional asphyxia in the
last 5 years. The majority of agencies, 58.5%, did not prohibit the transportation
of prisoners in the prone position. The majority of agencies, 63.2%, did not
prohibit the hog-tying of prisoners. And, the majority of agencies, 80.3%, have
ﬁeld ofﬁcers trained to recognize positional asphyxia. Also, there appears to be
no signiﬁcant difference in reported deaths due to positional asphyxia between
agencies that prohibit the transportation of prisoner in the prone position and

those agencies that do not prohibit such transport. One can conclude in support

68

 

of the recent literature that transporting prisoners in the prone position does not,
in itself, cause death by positional asphyxia.

Additionally, these data indicate that the majority of law enforcement
agencies throughout the country have a real interest in issues related to sudden
in-custody death, positional asphyxia and restraint related issues. Agencies are
most likely modifying their policies as a result of the controversy surrounding
sudden in-custody death in an attempt to reduce the chance of such deaths
occurring in the future. Agencies that resist seem to do so at their peril. The idea
that leaving a suspect in a prone position with his hands cuffed behind the back,
or in a hog-tied position, can cause death appears to have become widely held
as true. Credibility for this widely held belief seems to have developed though
literary articles rather than scientiﬁc fact. Unfortunately, it may not longer matter
that the use of the hog-tie restraint position does not in itself cause death by
positional asphyxiation if the jury believes that positional asphyxia was the cause
of death.

Recent literature suggests several other possible causes for sudden in-
custody death, other than the prone position and hog-tying. Some researchers
have identiﬁed stressful life situations that may induce sudden death through
overwhelming excitation resulting in cardiac arrest and death (Engel, 1971).
Others suggest that sudden in-custody death may be due to positional asphyxia
as a result of alcohol or drug induced unconscious (suffocating positions), and
acute alcohol and or drug intoxication (reduced drive to breathe). Additionally, the

use of cocaine and alcohol have been identiﬁed as creating cardiotoxic (heart

69

damaging) effects, which signiﬁcantly increase the risk of sudden death (Perry &
McDonough, 1995).

It has also been suggested that sudden death may occur as a result of
adrenal hormone (epinephrine or catecholamine) overloads produced by extreme
levels of agitation caused by fear, panic, anxiety, and rage. A ﬂood of released
hormones during a violent struggle can induce abnormal heart rhythm. The
consumption of certain drugs such as cocaine and amphetamine, alcohol along
with stress can also lead to abnormal heart rhythm (Ross, 1997).
Catecholamines and methamphetamine have been identiﬁed as heart irritatants,
and it has been determined that methamphetamine can cause internal
derangements in the heart. People suffering from a cardiac arrest due to
methamphetamine-induced toxic delirium usually are not resuscitated (Pricey,
County of San [E99, 1998). Additionally, neuroleptic NMS, also known as “acute
exhaustive mania,” usually associated with anti-psychotic drugs, may also induce
sudden death (Pilant, 1996).

Cocaine intoxication has been identiﬁed as a contributing factor in 45% of
the reported sudden in-custody death cases. Cocaine psychosis has also been
identiﬁed as a known risk factor of sudden death and it has been linked to
approximately 37% of the sudden in-custody deaths that have occurred (Ross,
1997). Also, cocaine psychosis (excited delirium) has been identiﬁed as a
potentially lethal medical emergency. Individuals suffering from this condition can
die regardless of body position, no matter how carefully they are restrained,

despite the immediate availability of medical support (Burgeen et al., 1992).

70

Furthermore, many individuals suffering from cocaine induced excited delirium
die without ever being restrained, and it is not unusual for subjects to die at the
scene or during transport by paramedics to the hospital (Chan, et al., 1997).
Restraints in general can increase the psychological and physiologic
stress on an individual (Pilant, 1996). Out of control subjects should be controlled
as quickly and humanely as possible using restraints to minimize the risk of injury
to the subjects, ofﬁcers and citizens alike. Subjects should be regularly monitored
to identify potential problems (Stratton et al., 1995). It is suggested to follow the I?
practice of asking the restrained subjects every 15 minutes if they feel they can

control their behavior to successfully shorten the restraint time (Pilant, 1996).

 

Personnel should be aware of the potential complications of using physical
restraints for control of agitated subjects. Without proper training ofﬁcers may
lack conﬁdence and may become frustrated and may act irresponsibly. Ofﬁcers
need to be trained in the use of restraints.

Determining the cause of death of subjects who have been placed in the
hog-tied and prone position is one of the most difﬁcult tasks in all of forensic
medicine (Reay, 1996). Some coroners have misdiagnosed sudden in-custody
deaths as positional asphyxia deaths. It is critical that medical examiners do not
attribute deaths to positional asphyxia when a subject has been restrained just
because there are no other signiﬁcant life-ending pathological ﬁndings indicated
(Rosazza, 1996). If death occurs, law enforcement agencies must provide
medical examiners with a clear and complete description of preceding events, so

that doctors can determine, utilizing all information, the cause of death accurately

71

(Reay, 1996). There can be serious consequences in concluding that police
restraint and transport alone caused death. Correct certiﬁcation of death while in
police custody is essential to protect the public from undue harm and to protect
the police from wrongful allegations (Laposata, 1993).

There is little question that departmental policy is directly related to liability
and administrators must be aware of the negative effects liability suits can have
on an organization. Police executives should take proactive approaches to
reduce liability. A positive proactive training model will be very beneﬁcial to police
ofﬁcers and citizens alike. Police administrators should deﬁne and develop
training programs designed to prevent litigation. They should keep abreast of
new approaches to criminal apprehension techniques in order to avoid claims of
negligence or indifference for failing to adopt more prudent police practices.
There is no better way for administrators, ofﬁcers or departments to take action
to reduce and insulate themselves from liability litigation then to have a good
understanding of the law, have comprehensive written policies and procedures
and keep abreast with the current court decisions (Benson, Christian, & Payne,
1993)

This research suggests that sudden custody death can occur at any time
for a variety of reasons. Any law enforcement agency may experience a sudden
custody death, regardless of the degree of involvement. Police may potentially
avert sudden in-custody deaths by recognizing the symptomatology of those at
risk. Ofﬁcers my be able to render the appropriate aid or obtain assistance when

such an event occurs. If a fatality does occur, police can become familiar with the

72

 

problems associated with in-custody death investigations (Granﬁeld et al., 1994).
Although not all deaths can be prevented, the ﬁrst step in signiﬁcantly reducing
these incidents is through education, awareness, training, and recognition of the
symptoms (Postill & Rowan, 1998).

Additional studies should be conducted to further clarify the
pathophysiology behind these cases in the future. Improving the methods used
by public safety ofﬁcers and medical personnel for restraining violent individuals
would be substantially expedited by the availability of scientiﬁc and clinical

studies identifying the speciﬁc causes of death and injury during restraint (Chan,

 

I" ‘
I
.

Vilke, Newman & Clausen, 1998). As we proceed into the future, we need to be
more safety conscious. Law enforcement personnel must recognize that when
force is used, those using the force must be adequately supervised and the
incident properly reported. The best that can be done is to be familiar with the
nature of in-custody deaths, try to foresee and prevent them, and encourage

further research in this area.

73

APPENDICES

 

APPENDIX A

SURVEY QUESTIONNAIR INSTURMENT

Tracking No.

1999 Prisoner Restraint Survey

This questionnaire is designed to elicit information concerning prisoner
restraint and prisoner transportation relevant to hobbling or hog-tying and
positional asphyxia. For the purpose of this study, hobbling, hog-tying, and 4-
point restraint are deﬁned as persons placed in a prone position with their wrists
handcuffed or tied together behind their backs and their ankles bound together
and secured to their wrists. Positional asphyxia is a body position resulting in a

person’s inability to breathe. Custody-death-syndrome is sudden unexplained
deaths of prisoners while in custody.

Each questionnaire is numbered in order to track responses. No agencies
will be named in this study unless prior permission is obtained; otherwise, all
agencies will remain conﬁdential. Please check or indicate the appropriate
response to the question and feel free to comment. Place the completed survey
in the self addressed stamped envelope and return it to us as soon as possible.

SECTION 1: Prisoner Transportation

1. Does your agency have a policy that addresses the transportation of
prisoners?

El Yes. If yes, go to question 1a.
El No. If no, go to question 2.

1a . Are your ﬁeld ofﬁcers trained in prisoner transportation?

El Yes.
El No.

1b. Are your ﬁeld ofﬁcers trained in the transportation of
prisoners in the prone position?

Cl Yes.
C] No.

75

 

1c. Does your policy prohibit the transportation of prisoners in
the prone position?

El Yes.
E] No.

1d. When transporting prisoners in the prone position, does you
policy recommend turning the prisoner on his/her side, if
doing so does not expose ofﬁcers to unnecessary risk?

I] Yes.
[I No. I:
1e. When transporting prisoner(s) in the prone position, does '
your policy recommend constant monitoring of the prisoner.

Cl Yes.
El No.

 

2. Has your agency ever had any deaths attributed to prisoners transported in L,
the prone position within the last ﬁve years?

El Yes.
D No.
Cl Not Known.

3. Has your agency ever been sued for transporting a prisoner in the prone
position within the last ﬁve years?

III Yes.
El No.
[3 Not Known.

4. Is your agency considering developing a policy that addresses the
transportation of prisoners in the prone position?

El Yes.

El No.

El Not Known.

El Already have a policy.

SECTION 2: Restraint - Handcufﬁng and Hog-Tying

5. Does your agency have a policy that addresses prisoner restraint and
handcuffing?

El Yes.
E] No.

76

6. Are your ﬁeld ofﬁcers trained in prisoner restraint and handcufﬁng?

El Yes.
El No.

7. Does your agency use some form of leg restraint tool to control violent
prisoners?

E] Yes.
I] No.

8. Does your agency have a policy that addresses hog-tying a prisoner (i.e.,
wrists and ankles manacled or tied together from behind)?

El Yes. If yes, go to question 8a.
[II No. If no, go to question 9.

8a. Are your ﬁeld ofﬁcers trained in hog-tying a prisoner?

El Yes.
C] No.

8b. Does your policy prohibit hog-tying a prisoner?

El Yes.
E] No.

9. Has your agency had any deaths attributed to hog-tying a prisoner within the
last ﬁve years?

[I Yes.
El No.
II] Not Known.

10. Has your agency ever been sued for hog-tying a prisoner within the last ﬁve
years?

[I Yes.
El No.
C] Not Known.

77

 

11.ls your agency considering developing a policy that addresses hog-tying a

prisoner?

El Yes.
El No.

El Not Known.

l'_'l Already have a policy.

SECTION 3 —- Positional Asphyxia

12. Is your agency aware of the term positional asphyxia (i.e., body positions

resulting in a person’s inability to breathe)?

El Yes. If yes, go to question 12a. I

Cl No. If no, go to question 13.

12a.

12b.

12c.

12d.

Does your agency have a policy that addresses positional
asphyxia?

 

Ill“ _— - -SO._I -

[I Yes.
El No.

Are your ﬁeld ofﬁcers trained to recognize positional
asphyxia?

El Yes.
[II No.

Has your agency had any deaths attributed to positional
asphyxia within the last ﬁve years?

El Yes.
El No.
CI Not Known.

Has your agency ever been sued as a result of positional
asphyxia within the last ﬁve years?

D Yes.
D No.
El Not Known.

78

13. Is your agency considering developing a policy that addresses positional
asphyxia?

El Yes.

El No.

El Not Known.

[3 Already have a policy.

SECTION 4 — Custody Death Syndrome

14. Is your agency aware of the term in-custody sudden death syndrome (i.e.,
sudden unexplained deaths of prisoners while in custody)?

. " ‘u‘umhﬂ.’ ‘Aa‘z'fhﬁ
!

 

E] Yes. If yes, 90 to question 14a.
El No. If no, go to question 15.
14a. Does your policy address in-custody sudden death
syndrome? _‘
[:1 Yes.
E] No.

14b. Are your ﬁeld ofﬁcers trained to recognize in-custody sudden
death syndrome?

I] Yes.
El No.

140. Has your agency had any deaths attributed to in-custody
sudden death syndrome within the last ﬁve years?

El Yes.
[II No.
III Not Known.

14d. Has your agency ever been sued for in-custody sudden
death syndrome within the last ﬁve years?

III Yes.
[II No.
[II Not Known.

79

15. Is your agency considering developing a policy that address in-custody
sudden death syndrome?

El Yes.

I] No.

[I] Not Known.

El Already have a policy.

16. Has your agency developed any special procedures for dealing with suspects
displaying bizarre or violent behavior?

El Yes.
E] No.

COMMENTS:

Please return the completed survey in the enclosed self addressed stamped
envelope as soon as possible.

80

 

APPENDIX B

COVER LETTER TO AGENCIES

MICHIGAN STATE
U N l V E R S I T Y

January 29, 1999
Dear Sir:

My name is John F. Kennedy. I am a retired police ofﬁcer and a Masters
student at Michigan State University. For my thesis, I am sending this
questionnaire to your agency along with 153 other state and local agencies. The
purpose of this research project is to study policy development in the areas of
prisoner restraint and positional asphyxia to aid law enforcement agencies in
the development and implementation of their policies. This survey will take
approximately 15 minutes of your time to complete. Your response is very
important for scientiﬁc validity.

Your agency was scientiﬁcally selected from a sampling frame of
approximately 19,000 law enforcement agencies from a list provided to us by the
Bureau of Justice Statistics (BJS). No agencies will be named in this study
unless prior permission is obtained; otherwise, all agencies will remain
conﬁdential. The results will be reported in the aggregate form. Each
questionnaire is numbered in order to track responses. Your participation in this
study is voluntary. For participating in this study, your agency will receive a
summary copy of the analysis upon completion in hope that this research will be
useful to you.

Dr. David Carter, (517) 355-9308, of Michigan State University, School of
Criminal Justice, supervises this research project. Michigan State University has
always enjoyed an excellent reputation for aiding law enforcement agencies in
the development and implementation of their policies. You can help us greatly in
achieving our common goal of sharing knowledge and improving poligr
development by returning the completed survey questionnaire as soon as
possible. I have enclosed a self-addressed, stamped envelope to assist you in

81

 

promptly returning the survey. If you have any questions about this research or if
I may assist you in another way, feel free to contact me at (517) 355-5884.

Thank you,

John F. Kennedy

Michigan State University

School of Criminal Justice

560 Baker Hall

East Lansing, MI 48824-1118

Tel.: (517) 355-9308, (517) 355-5884
E-mail: jkennedy@pilot.msu.edu

82

 

APPENDIX C
FOLLOW UP LETTER TO AGENCIES

MICHLGAN STATE
U N IV S E S I TY

February 15, 1999
RE: Second Request.
Dear Sir:

Recently you were mailed a short questionnaire about policy development in the
areas of prisoner restraint and positional asphyxia. The purpose of this
research is to aid law enforcement agencies in the development and
implementation of their policies. Your response is key in making this a
successful research effort and is very important for scientiﬁc validity.

As of now, we have not received your questionnaire. If you have already returned
your questionnaire, this is my way to say thank you. If not, please take the time to
do so soon. The questions are relatively easy to complete and should take only a
few minutes of your valuable time.

Your answers will be kept strictly conﬁdential. It is not necessary to place your
name or your agency name on either the questionnaire or the envelope. Please
return the questionnaire in the enclosed self addressed stamped envelope
provided. The tacking will be used only to identify responding agencies. By
completing this survey, you will be sure to receive a summary copy of the
analysis upon completion in hope that this research will be useful to you.

Thank you,

John F. Kennedy

Michigan State University

School of Criminal Justice

560 Baker Hall

East Lansing, MI 48824-1118

Tel.: (517) 355-9308, (517) 355-5884
E-mail: jkennedy@pilot.msu.edu

P.S. Perhaps the original questionnaire was misplaced, therefore I am
enclosing another questionnaire and return envelope.

83

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