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Investigation and
Prevention of
Officer-Involved
Deaths
Investigation and
Prevention of
Officer-Involved
Deaths
Cyril H. Wecht, JD, MD
Forensic Pathologist

Henry C. Lee, PhD

Professor, University of New Haven

D.P. Van Blaricom

MPA, Chief of Police (Ret)

Mel Tucker
MPA, Chief of Police (Ret)

Illustrations:
Scott G. Roder/Roder Evidence Consulting

Boca Raton London New York

CRC Press is an imprint of the

Taylor & Francis Group, an informa business
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2011 by Taylor and Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed in the United States of America on acid-free paper

10 9 8 7 6 5 4 3 2 1

International Standard Book Number-13: 978-1-4200-6375-2 (Ebook-PDF)

This book contains information obtained from authentic and highly regarded sources. Reasonable efforts
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Table of Contents

Preface xiii
About the Authors xvii

1 Reducing and Preventing Deaths by Training

and Policy Guidance 1
High-Risk Business 1
Civil Liability 2
Negligence 2
Civil Rights 2
Law Enforcement Training 2
Contemporary Law Enforcement Training 4
Basic Recruit and In-Service Training Programs 4
The Field Training Officer Program 4
Job Task Analysis and Training 5
The Need for Change and Leadership 5
Training to Prevent Mistakes and Liability 5
Focused Training on Authority to Use Force 6
Focused Training on Preemptive Action 6
Policies Can Reduce Deaths 8
Supreme Court Decisions on the Use of Force 8
Policy Guidance and Domestic Violence 9
The Exercise of Discretion 9
Prevention of Illegitimate Exercise of Discretion 10
National Advisory Commission on Criminal Justice
Standards and Goals 10
Variables 10
Policies and Procedures 11
The National Law Enforcement Policy Center 11
Police Policies and Official Immunity 12
Identification of Areas in Which Policy and Procedure
Guidance Is Needed 12
Summary 12
Endnotes 13

v
vi Table of Contents

2 Less-Lethal Weapons 15
Reducing Injury and Death 16
Types of Incidents 16
Less-Lethal Not Required by Law 16
The Ideal Less-Lethal Weapon 17
The National Law Enforcement Technology Center 17
Capture Devices 18
Impact Weapons (Beanbags) 19
Pepper Sprays (Oleoresin Capsicum) 19
Conducted Energy Devices (CEDs) 20
Operational Success of CEDs 22
Scenario 22
How Would You Have Handled the above Scenario? 24
Summary 25
Endnotes 26

3 Officer-Involved Shootings (OISs) 29

What Would You Have Done? 30
Best Practices 32
Crime Scene Investigation 32
The Crime Scene Search 34
Collection, Preservation, and Packaging of
Physical Evidence 34
Preliminary Reconstruction 35
Releasing the Scene 35
Laboratory Analysis and Reconstruction 36
Cartridge Cases / Shells 36
Weapon Examination 36
Gunshot Residues (GSR) 37
Examination of Ricochet Bullets 37
Bloodstain Pattern and Tissue Examination 38
Reconstruction 39
Pathology / Medical Examination 41
External Examination 41
Postmortem Changes 42
Therapeutic Procedures 42
Clothing 42
Injuries: External and Internal 43
Perforating Gunshot Wound to Anterior Chest 43
Perforating Gunshot Wound to Mid-Left Trunk 43
Table of Contents vii

Perforating Gunshot Wounds (4) to Left Aspect of the

Lower Trunk 44
Perforating Gunshot Wound to Left Back 45
Perforating Gunshot Wound to Right Elbow 45
Perforating Gunshot Wounds (2) to Lateral Aspect of
Left Thigh 46
Penetrating (1) and Perforating (1) Gunshot Wounds to
Posterolateral Aspect of Left Thigh 46
Perforating Gunshot Wounds (2) to Left Lower Extremity 47
Perforating (Gunshot Wounds O, P, R) and Penetrating
(Gunshot Wounds Q and S) Gunshot Wounds to Right
Lower Extremity 48
Internal Examination 49
Body Cavities 49
Head 49
Neck 50
Cardiovascular System 50
Respiratory System 50
Liver, Gallbladder, Pancreas 50
Hemic and Lymphatic Systems 50
Genitourinary System 50
Endocrine System 51
Digestive System 51
Musculoskeletal System 51
Additional Studies 51
Bullet Evidence 51
General Evidence 51
Final Diagnoses 52
Cause of Death 52
Manner of Death 52
Endnotes 52
Appendix: IACP National Law Enforcement Policy Center
Concepts and Issues Paper Titled “Investigation of
Officer-Involved Shootings” (August 1999) 53
Notes 68

4 Emergency Vehicle Operations 71

What Would You Have Done? 73
Investigation of Accidents 75
Crime Scene Investigation 77
Best Practices 83
viii Table of Contents

Pathology 85
Autopsy Report of Police Shooting during Pursuit 85
Evidence of Recent Trauma 86
Other Evidence of Trauma 89
Internal Examination 89
Body Cavities 89
Neck 89
Cardiovascular System 90
Respiratory System 90
Hepatobiliary System 90
Hemolymphatic System 90
Gastrointestinal System 91
Urogenital System 91
Endocrine System 91
Musculoskeletal System 91
Central Nervous System 91
Microscopic Examination 92
Endnotes 92
Appendix: IACP Vehicular Pursuit Policy 93

5 Excited Delirium 97
What Would You Have Done? 99
Best Practices Based upon What We Know 101
Investigation of the Scene 102
General Crime Scene Procedure 103
Line or Strip Methods 104
Grid Method 104
Wheel Method 104
Spiral Method 105
Zone Search 105
Link Search 106
Collection, Preservation, and Packaging of Physical Evidence 106
Preliminary Reconstruction 107
Releasing the Scene 107
TASER and Excited Delirium 107
Other Cases Involving Excited Delirium 109
Model Legislation for the Safe Use of TASERS 110
Endnotes 111

6 Suicide-by-Cop (SbC) Incidents 113

Indicators of Suicide-by-Cop 113
A Typical SbC Scenario 114
Table of Contents ix

What Would You Have Done? 116

SbC Resolution Tactics 116
Investigation at the SbC Scene 118
General SbC Scene Procedures 119
Conducting the SbC Crime Scene Survey 119
Documentation of the Crime Scene 120
Crime Scene Search 120
Collection, Preservation, and Packaging of
Physical Evidence 120
Assignment of Responsibility 121
Preliminary Reconstruction 122
Releasing the Scene 122
Summary of Crime Scene Procedures 123
Suicide-by-Cop, Autopsy Report 123
External Examination 123
Evidence of Recent Trauma 124
Other Identifying Features 126
Internal Examination 126
Microscopic Examination 128
Anatomic Diagnoses 129
Opinion 129
Manner of Death 129
The Future 129
Endnotes 130

7 Positional Asphyxiation 131

What Would You Have Done? 131
Best Practices 133
Crime Scene and Forensic Evidence 134
General Procedures 134
Indoor Scene Procedure 134
Crime Scene Survey 135
Documentation of the Crime Scene 135
Crime Scene Search 136
Collection, Preservation, and Packaging of
Physical Evidence 137
Preliminary Reconstruction 138
Autopsy Report 1—Positional Asphyxia Death 138
External Examination 138
Internal Examination 142
Body Cavities 142
Cardiovascular System 142
x Table of Contents

Respiratory System 143

Hepatobiliary System 143
Hemolymphatic System 143
Gastrointestinal System 143
Pancreas 144
Urogenital System 144
Adrenals 144
Musculoskeletal System 144
Neck 144
Central Nervous System 144
Microscopic Examination 145
Heart 145
Lungs 145
Trachea 145
Liver 145
Pancreas 146
Kidneys 146
Left Side of Scalp (Slides 1 and 2) 146
Left Temporalis Muscle 146
Anatomic Diagnoses 146
Opinion 147
Manner of Death 147
Autopsy Report 2—Positional Asphyxia Following TASER 147
External Examination 147
Remainder of External Examination 150
Internal Examination 151
Head 151
Vertebral Column and Spinal Cord 151
Oral Cavity 152
Neck 152
Internal Organs 152
Penis 153
Final Pathological Diagnoses 153
Sample Report of Opinions of a Coroner’s Office 153
Summary 156
Endnotes 156

8 In-Custody Deaths 157

What Would You Have Done? 158
Example—Pathological Examination 159
Gross Description 160
General 160
Table of Contents xi

External Evidence of Therapy 160

Articles of Clothing 160
General 161
External Evidence of Trauma 162
Internal Evidence of Trauma 164
Primary Incision 164
Body Cavities 164
Heart 165
Lungs 166
Mediastinum 166
Gastrointestinal System 166
Liver 167
Pancreas 167
Lymph Nodes 167
Spleen 167
Kidneys 167
Urinary Bladder and Internal Genitalia 167
Endocrine System 168
Cardiovascular System 168
Musculoskeletal System 168
Central Nervous System 168
Special Studies 169
Cause of Death Based on Gross Findings at Conclusion
of Autopsy and Pending Ongoing Official Investigative
Findings, Toxicological and Histological Studies 169
Manner of Death 169
Medical Treatment of Prisoners 170
Best Practices 171
Endnotes 172

9 Emotionally Disturbed Persons 173

What Would You Have Done? 176
Best Practices 178
Crises Intervention Teams 179
Crime Scene and Forensic Evidence 179
General Scene Procedure 181
Crime Scene Investigation 181
The Crime Scene Search 182
Collection, Preservation, and Packaging of
Physical Evidence 182
Preliminary Reconstruction 183
Releasing the Scene 183
xii Table of Contents

Laboratory Analysis 183

Cartridge Cases/Shells 184
Weapon Examination 184
Gunshot Residues 184
Examination of Ricochet Bullets 185
Bloodstain Pattern and Tissues Examination 185
Reconstruction 186
Endnotes 186

Index 187
Preface

A great philosopher once stated that he could readily determine the level and
extent of any civilization by studying the way in which police officers func-
tion and the manner in which penal institutions are conducted. It is with
that maxim in mind that the authors undertook to compile the contents of
this book.
Each year, approximately 150 law enforcement officers die while per-
forming their duties. For the first part of this century, the majority died when
engaged by suspects with firearms. In addition to officer deaths, there are
approximately 375 people killed each year by the police. Between 2000 and
2008, there were 3,000 people killed by the police who were classified by the
Federal Bureau of Investigation (FBI) as justifiable homicides. Over 98% of
those were shot to death with a firearm.1
In recent years, more officers have died from accidents while on duty
than by a felon with a firearm. Approximately 36% of all officer line-of-duty
deaths in recent years have been vehicle-related. In addition, hundreds of
innocent bystanders die each year when involved in a collision with a police
car or fleeing vehicle while operating their vehicle, or when struck by a police
car or fleeing vehicle while walking. Although there is no national data-
base, it is estimated by the National Highway Traffic Safety Administration
(NHTSA) that the police are involved in about 70,000 police chases each year
resulting in the deaths of 400 innocent people.2
Most people would agree that police officers whose daily assignments
require them to be directly engaged in various kinds of potentially danger-
ous situations have a grave responsibility to protect innocent bystanders as
well as themselves. In our democratic society, it is also incumbent upon the
law enforcement official to utilize only as much potentially lethal force as
necessary regarding those individuals who are pursued, arrested, and incar-
cerated for obvious, alleged, or suspected crimes. A valid and logical argu-
ment can be made that there is no dichotomy between these two pragmatic
objectives. The physical safety and well-being of the uninvolved third party
and the police officer most often flow in a parallel fashion with the nonviolent
apprehension of the “actor.”
Of course, there are numerous scenarios in which the police officer has
no alternative but to employ the full force of his or her weaponry in pursuing,
arresting, and subduing a dangerous, violent individual. Regrettably, these
kinds of situations result in the tragic deaths of many law enforcement officers

xiii
xiv Preface

every year in the United States. Unfortunately, many deaths of completely

innocent third parties and potential victims also occur as a consequence of
such violent confrontations between police and suspected criminals.
What about the larger number of people whose deaths annually are
directly or indirectly related to the actions of law enforcement officials during
pursuit, apprehension, arrest, and incarceration? Should our society ignore
these deaths and simply attribute all of them to unchallengeable professional
decisions and necessary acts of police? Or does it behoove an advanced civi-
lization like ours to objectively review all such police-related deaths in a dili-
gent, thorough, open, and unbiased fashion in order to determine what the
circumstances were that ultimately resulted in that individual’s death?
Analysis and examination of police-related deaths are not solely under-
taken to retrospectively ascertain whether the involved officer acted in a deliber-
ately improper or unintentionally negligent fashion. Such reviews are certainly
intended to accomplish that objective, which is necessary for moral, ethical, and
legal reasons. However, there is a more overarching purpose for these kinds of
postmortem case studies—namely, the continuing, advanced education of all
active-duty police officers and other law enforcement officials so that they can
better serve themselves and the society in which they function.
The authors created several representative scenarios of officer-involved
deaths from their extensive professional experiences. The examples that fol-
low describe circumstances wherein law enforcement officers have had to
respond to critical incidents that are outside of their usual experience and
have unfortunately resulted in the death of the person they were trying to
take into custody. It is the authors’ intent to show that an examination of
such incidents will serve to better inform law enforcement practitioners on
how to thoroughly investigate officer-involved deaths and thereby learn how
they might have been prevented.
The major and most frequently occurring kinds of police-related deaths
are set forth on a chapter-by-chapter basis. In each category, a hypotheti-
cal, quite realistic scenario is presented. With such a background scenario
in place, relevant discussions then follow dealing with the important and
critical issues that need to be considered and evaluated from the perspective
of law enforcement officials, criminalists, forensic pathologists, and other
forensic scientific experts.
One of the most important areas in investigation of police-related deaths
is the crime scene investigation and the collection and preservation of the
relevant forensic evidence to prove or disprove certain issues and hypotheses.
We have outlined the appropriate crime scene procedures for each situation
and listed the potential categories of forensic evidence that should be searched
for, collected, and sent to the forensic (crime) laboratory for analysis. Those
laboratory analysis procedures are set forth in many laboratory manuals and
textbooks, and therefore are not included in this book.
Preface xv

Postmortem protocols, consisting of autopsy reports, toxicological anal-

yses, and other appropriate investigative findings depicting particular types
of police-related deaths are included.
Studies of police-related deaths have shown that restrictive policies in
high-risk police activities save lives. Accordingly, we included a chapter deal-
ing with policy and training.
It has also been demonstrated that police use of less-lethal weapons can
save lives. Hence, we included a separate chapter that discusses less-lethal
weapons.
The authors pose the critical question—“What would you do if you were
the police officer?”—in each of the scenarios that are presented to challenge
the reader.
The authors believe that a serious study of each of the categories presented
in this book will enable police officers and other groups of law enforcement
officials to more fully comprehend and appreciate the societal significance of
such cases. The more aware, sensitive, and well-educated that officers of the
law are, the more dignified, humane, and safe the communities that they are
sworn to serve will be.
No law enforcement officer wants to be involved in a death that could have
been avoided by a better understanding of a particular dynamic with which
he or she may be suddenly confronted. Accordingly, a thorough investiga-
tion will lead to a better understanding of what has occurred and encourage
improved training for future similar events. The authors understand that not
all officer-involved deaths can be prevented. However, we believe that some
can. The information provided in this book should be helpful in achieving
that highly desirable goal.
We greatly respect the difficult duties that our dedicated law enforce-
ment officers perform and hope to make some of their dangerous encounters
safer for them.

Endnotes
1. U.S. Department of Justice, Federal Bureau of Investigation, Crime in the United
States.
2. Voices Insisting on Pursuit SAFETY (VIPS) (www.pursuitsafety.org).
About the Authors

Cyril H. Wecht, J.D., M.D., is one of this country’s leading forensic pathol-
ogists. He received his medical degree from the University of Pittsburgh
School of Medicine. He also holds a law degree from the University of
Maryland School of Law. As a medical expert, he has performed more
than 17,000 autopsies and has reviewed or supervised over 36,000 addi-
tional postmortem examinations. Dr. Wecht is a former president of
the American College of Legal Medicine and the American Academy of
Forensic Science. He is a fellow of the College of American Pathologists
and the American Society of Clinical Pathologists. He has served as a
medical-legal and forensic pathology consultant in civil and criminal
­t rials since 1962.

Henry C. Lee, Ph.D., is one of the world’s foremost forensic scientists. He has
worked on most of the challenging cases that have occurred during the past
40 years, including the O.J. Simpson trial, the JonBenet Ramsey investigation,
the suicide death of White House Counsel Vincent Foster, and the reinvesti-
gation of the John F. Kennedy assassination. Dr. Lee was the Commissioner
of Public Safety for the State of Connecticut and was their Chief Criminalist
from 1979 to 2000. He is currently Chair Professor of Forensic Science
University of New Haven (Connecticut) and Director of The Henry C. Lee
Research and Training Center (also at the University of New Haven).

D. P. Van Blaricom began his law enforcement career in 1956 as a patrol offi-
cer with the Bellevue Police Department (Washington). He later served as a
detective, sergeant, captain, and deputy chief before being selected as the Chief
of Police in 1975, where he served until his retirement in 1985. Since his retire-
ment from active law enforcement, Van Blaricom has served as a litigation
consultant in over 1,500 law enforcement cases throughout the United States.

Melvin L. Tucker began his law enforcement career as an FBI Agent in 1969
and served as a police chief for four cities in three states before retiring from
active law enforcement service as the Chief of Police for the City of Tallahassee,
Florida, in 1994. Since his retirement, Tucker has served as a litigation con-
sultant in over 450 law enforcement cases throughout the United States.

xvii
Reducing and Preventing
Deaths by Training
and Policy Guidance 1
Law enforcement has become a big business. There are now 17,876 state
and local law enforcement agencies in the United States employing 731,903
­officers.1 The total direct expenditure for federal, state, and local law enforce-
ment has now reached $185 billion annually.2 Because law enforcement is
now a big business and is routinely involved in arresting and detaining peo-
ple; engaging in vehicle pursuits; using force to overcome resistance to arrest;
and searching homes, people, and vehicles, there are officers, suspects, and
innocent citizens who suffer injury and death when suspects resist violently
or poor tactics and judgment are used by officers. During the past century,
over 14,000 federal, state, and local law enforcement officers were killed in
the line of duty. Of those killed, 49% were shot to death, making it the single
leading cause of officer deaths.3
In addition to officer deaths, approximately 375 people are killed each
year by the police. These deaths end up being classified by the Federal Bureau
of Investigation (FBI) as justifiable homicides. Over 98% of the justifiable
homicides involve people who were shot to death with a police firearm.4
Vehicle-related activities (motorcycle or automobile accidents or struck
by vehicle) were the second leading cause of death of law enforcement officers
over the past century, accounting for approximately 30% of all officer line of
duty deaths.
In addition, hundreds of innocent bystanders are killed each year when
struck by or involved in a collision with a police car or fleeing vehicle. Although
there is no national database, it is estimated by the National Highway Traffic
Safety Administration (NHTSA) that the police are involved in about 70,000
police chases each year, resulting in the deaths of 400 innocent people.5

High-Risk Business

Police officers wear uniforms and drive cars with emergency lights and agency
markings. As a consequence, their activities are noticed by the public. When
they make mistakes, they, and their employing agency, are often subjected to
lawsuits seeking monetary relief for the harm incurred.
One of the most frequent allegations made against law enforcement officers
is that they used unnecessary or excessive force in carrying out their duties. In
2002, there were 22,238 citizen complaints against municipal law enforcement
officers alleging unnecessary or excessive force; 2,815 against sheriff’s deputies;
1
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