By: Darrell L. Ross, Ph.D.
A non-firearm, arrest-related death (ARD) involves a subject’s death in custody temporally associated with an LEO’s use of force during an arrest, due to the arrestee’s medical condition, during transport to a lock-up or jail, and/or transport to a medical facility.1
Common issues associated with an ARD have been addressed in two previous articles in the 2021 Winter and Spring editions of The Georgia Police Chief. While rare in occurrence, an ARD poses numerous complex and multi-factor issues including: associated medical and mental health condition of the subject; the subject’s history of abusing illicit drugs; symptoms associated with Excited Delirium Syndrome (ExDS); and the use of force and restraint measures applied. As a result of the death, liability claims of excessive force are commonly filed as well as claims that the agency administrator failed to direct officers through appropriate policies and protocols and failed to train the LEOs on responding to persons experiencing “diminished capacity.” 2
This third article of four describes protocols that may be implemented in association with an agency’s Response to Resistance Policy and also describes officer training recommendations. Recognizing that each incident presents unique circumstances based on innumerable risk factors and variables and the changing operating incident environment, evidence-based recommendations represent guidelines for LEOs response when confronted with a subject exhibiting violent behaviors.
Subject Contact Dynamics
Responding to a call of a subject who “just snapped,” is screaming, acting strangely and highly agitated, running in and out of traffic, threatening violence toward others, and engaging in self-injurious behaviors can be one of the most dangerous calls for an LEO. The dynamics of the contact commonly show that the subject is non-responsive to attempts of verbal de-escalation, vigorously struggles against the LEOs use of various less-lethal force techniques and options,
and is controlled and restrained in handcuffs in the prone position. Unexpectedly, the once combative subject is observed to be quiet and unresponsive. Resuscitation efforts by LEOs and paramedics are unable to revive the person. In a significant number of cases, the cause of death is a cardiac arrest but in many incidents the cause of death is undetermined.3-6 The medical examiner (ME) may conclude that the person’s psychosis associated with their mental illness, and the abrupt stoppage of taking his prescribed medications, combined with a chronic history of abuse illicit drugs, underscoring the features of ExDS, and diseased internal organs, all contributed to the death. In some incidents the ME may conclude that the LEO’s use of force measures were contributory and classify the death as a homicide, despite the medical condition of the subject.7 Research reveals that two populations are potentially at risk of an ARD.8-9
First, it is estimated that in about
60 percent of these deaths, the
subject’s agitated, bizarre, hyper-aggressive, manic, and violent behaviors are associated with the use and a history of abusing illicit drugs. Second, subjects with psychiatric illness comprise about 30 percent of the ARDs, and commonly the research shows that an abrupt cessation of psychotherapeutic medication contributed to the death. The remaining 10 percent involve those subjects with a psychiatric illness who abuse illicit drugs and/or combine taking their medications with illicit drugs. The manifested behaviors of the subject during the contact commonly align with the symptoms associated with ExDS and subjects exhibiting six or more symptoms elevate their risk of sudden death during the control and restraint process.10-12
Fifth, while the probability of an ARD
occurring with these two populations is rare during an LEO contact, research shows that LEO contacts with these subjects is quite frequent as 63 percent of the jail detainee population meet the criteria for drug use, dependence, and abuse.13
Further, 26 percent of the jail detainees met the diagnosis for serious psychological disorder.14 Moreover, the probability of an LEO contacting a subject with a psychological disorder is estimated to account for about 11 to 20 percent of the calls for service, 80 percent of contacts were repeat calls with the same person, 87 percent required the use of force, and 32 percent resulted in an injury sustained by the responding LEO.15-16 Because of the frequency of the contacts with these two populations, and many contacts requiring the use of force, the following protocols are recommended.
Response Policy and Protocols
Agency administrators should ensure that their Response to Resistance policy is current and reflects the standard of objective reasonableness and the force assessment criteria as established in the United States Supreme Court’s decision in Graham v. Connor, 490 U.S. 386 (1989) and their progeny.17-20 The policy should direct the LEO to justify a level of force based on the subject’s resistance, within the facts and totality of circumstances of the incident, based on the perception of the LEO, and allow for split-second decision making during tense and rapidly evolving circumstances. The policy should identify and integrate the application of crisis intervention and de-escalation techniques as appropriate with authorized empty-hand control techniques, intermediate weapons, including less-lethal projectiles, the application of restraints, including the use of a hobble, and the use of deadly force. The policy should direct an LEO to intervene when another LEO uses excessive force. The policy should address monitoring the subject, providing access to medical attention to the subject as warranted, and require the LEO to submit a report after the incident.
Accompanying the Response to Resistance policy, administrators should consider implementing the following general response protocols for subjects in crisis. By practice, the protocols should emphasize LEO safety during the intervention. Dispatch should obtain as much information about the subject’s behaviors as possible and solicit information from the caller consistent with the symptoms of ExDS. As feasible, dispatch should send multiple LEOs to the location, including a supervisor. Ideally, dispatch should also request emergency medical care services to stage near the location simultaneously with the LEOs.21-22
On location, LEOs should turn off sirens and overhead lights of their patrol vehicle, assess the volatility of the situation while remaining alert to the contact environment, and assess the subject’s behaviors and statements, as time permits. As feasible, an LEO should request backup and make radio transmissions at varying intervals during the contact.
The LEO should remove any bystanders unless there is an immediate safety issue with the subject. The LEO is not expected to make a diagnosis but rather to assess the associated risks, including: the subject’s statements/or no statements made, threats made by the subject, movements and aggressive behaviors of the subject, the changing behaviors, physical posturing and moving toward the LEO, and possession of and/or access to potential weapons.21-22
The LEO should calmly approach the subject keeping a safe distance, assume a nonthreatening manner, and be mindful of areas for possible cover. As feasible, the LEO should use time as a tactic to allow other LEOs to respond. To minimize the fear of the subject, one LEO should make verbal contact with the subject using reassuring statements, and attempt to contain the subject in an area which will minimize harm to the subject. The LEO should attempt to talk the subject into cooperating with the LEO and EMS personnel. However, an LEO should be prepared at all times for a rapid change in the subject’s behaviors. 21-24
If the subject cannot be calmed and verbal de-escalation is unsuccessful, the decision to capture the subject will be made by a supervisor or other LEO on scene. If EMS personnel are on scene, they should be notified as feasible, so that after capture, control, and restraint is secured, they can provide appropriate medical attention. LEOs should base their decision to use force options on the active resistance and behaviors of the subject.
The objective is rapid control and restraint of the subject in order to minimize a prolonged struggle and exertion, whereby mitigating the risk of sudden death. The application of the Conducted Energy Weapon should be considered when confronting an active resisting and combative subject as opposed to using empty-hand control techniques as it can shorten the confrontation time span and reduces the propensity for subject and LEO injury.
Multiple officers should prone the subject to the ground by controlling the limbs of the subject, quickly restrain the subject’s hands behind his back (using 2 or 3 sets depending on the size of the person), and hobble the subject’s ankles as warranted.21-27
Once the subject ceases resistance LEOs should cease their use of force.
An LEO should monitor the subject’s face and check for breathing and vital signs, check for signs of functional consciousness, check for apparent injuries, and remove items from the neck of the subject.7
An LEO should initiate lifesaving measures until relieved by EMS if
the subject becomes unresponsive. The subject should be transported to a medical facility by EMS. All involved LEOs should submit a written report documenting their observations and of force measures applied.
Field research has shown that LEOs trained in recognizing symptoms associated with ExDS can prepare them to respond to a combative subject and training focused on these symptoms should be provided.10-12
LEOs should complete training which focuses on their response to the mentally ill, subjects whose behaviors align with being under the influence of a chemical substance, and subjects who may be emotionally disturbed. By practice, training should be provided which brings LEOs, dispatchers, supervisors, emergency medical and mental health personnel, and investigators together to focuses on the tasks of each position to provide a collaborative and coordinated response, when feasible, when LEOs confront a subject exhibiting symptom of ExDS.
LEOs should receive training in the agency’s Response to Resistance policy and the accompanying protocols on an ongoing basis.
Administrators should send LEOs
and supervisors to obtain and maintain instructor certifications in subject control tactics, force equipment, and associated topics relevant to
the subject. Training which matches policy and the protocols, and integrates the use of force options including restraints based on the changing dynamics of the circumstance and resistance of the subject and the application of a multi-LEO team takedown procedure should be practiced on a regular basis.2, 20
Training on using CIT or equivalent intervention techniques, force options and tactics, prone restraint procedures, First Aid, CPR, agonal breathing, and use of the Automated External Defibrillator should be integrated into scenario-based training drills to ensure linkages between concepts and skills are learned.2 10-12, 28-31 The training should emphasize that capture, control, and restraint of a combative subject should be applied quickly to minimize the subject’s exertional activity so that once the person is controlled and restrained, EMS personnel may provide appropriate medical attention. All training provided should be documented.
Guiding an LEO’s decision in using varying force measures, as described in the agency’s Response to Resistance policy, ensures administrators comply with the United States Supreme Court’s decision in Monell v. Department of Social Services, City of NY, 436 U.S. 658 (1978) by directing them in the performance of their duties through implementing constitutional policies.32
Further, agency administrators show compliance with the Court’s decision in City of Canton v. Harris, 489 U.S. 378 (1989) by providing realistic training for LEOs to recurring job tasks. Administrators exercise effective leadership by developing policies and providing training consistent with these court decisions which illustrate to the public that they have implemented constitutional policing practices while maintaining a strong commitment to equipping their LEOs to reasonably respond to volatile encounters.
Dr. Darrell L. Ross, Ph.D., is Professor and Department Head of the Department of Sociology, Anthropology, and Criminal Justice at Valdosta State University. He has published over 80 articles, 4 books, and 4 book chapters including Criminal Liability in Criminal Justice, 7th Edition (2018) and Civility Liability in Corrections (2005).
1. United States Department of Justice (July 2019). Arrest-related deaths program: Pilot study of redesigned survey methodology. Bureau of Justice Statistics, Washington D.C.; 1-18: www.bjs.gov/content/pub/pdf/ardppsrsm.pdf.
2. Ross, DL and Brave M (2020). Assessing use-of-force liability and law enforcement response to the naked subject. Law Enforcement Executive Forum, 20 (1):1-21.
3. Vilke GM and Jason Payne-James J (2016). Excited delirium syndrome: aetiology, identification and treatment. In J. Gall and J. Jason Payne-James (Eds., 2nd Vol.), Current Practice in Forensic Medicine, Chapter 6: 97-117.
4. Karch SB (2012). Possible strategies for the diagnosis of fatal excited delirium syndrome. Academy of Forensic Pathology, 2 (3):273-283.
5. Vilke GM, DeBard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, et al. (2011). Excited delirium syndrome (EXDS): Defining based on a review of the literature. Journal of Emergency Medicine, 1-9.
6. Krezi L, Georgiou R, Krezi D, Sheppard MN (April 2016). Sudden cardiac death with stress and restraint: The association with sudden adult cardiomyopathy and coronary artery disease. Journal of Medicine, Science and the Law; 56 (2):85-90.
7. Kroll MW and Brave M (2020). Defending non-firearm arrest-related death incidents. Paper presentation at the International Municipal Lawyers Association Mid-Year Seminar, Washington, D.C.; 1-19.
8.The International Association of Chiefs of Police Law Enforcement Policy Center (April 2017). Excited delirium: Concepts and issues paper and model policy; 1-6, 1-3: www.theiacp.org/policycenter.
9. American College of Emergency Physicians (September 2009). White paper report on excited delirium syndrome; 1-24: www.ojp.gov/ncjrs/virtual-library/abstracts/white-paper-report-excited-delirium-syndrome.
10. Hall C, Kader A, McHale A, Stewart L, Fick G, and Vilke GM (2012). Frequency of signs of excited syndrome in subjects undergoing police use of force: Descriptive evaluation of prospective, consecutive cohort. Journal of Forensic and Legal Medicine; 1-6.
11. Baldwin S, Hall C, Bennell C, Blaskovits B, and Lawrence C (2016). Distinguishing features of excited delirium syndrome in non-fatal use of force encounter. Journal of Forensic and Legal Medicine; 21-27.
12. Ross DL and Hazlett ML (2018). Assessing symptoms associated with excited delirium syndrome and the use of conducted energy weapons. Forensic Research and Criminology International Journal; 6 (3):187-196: www.medcraveonline.com/FRCIJ/assessing-the-symptoms-associated-with-excited-delirium-syndrome-and-the-use-of-conducted-energy-weapons.
13. Bronson J, Stroop J, Zimmer S, and Berzofsky M (August 2020). Drug use, dependence, and abuse among state prisoners and jail inmates, 2007-2009. US Department of Justice, Bureau of Justice Statistics, Washington, D.C.: www.bjs.gov/content/pub/pdf/dudaspji0709.pdf.
14. Bronson J and Berzofsky M (June 2017). Indicators of mental health problems reported by prisoners and jail inmates, 2011-2012. US Department of Justice, Bureau of Justice Statistics, Washington, D.C.: www.bjs.gov/content/pub/pdf/dudaspji0709.pdf.
15. Lexipol (May 2019). Law enforcement response to people in crisis: Understanding the challenges of incidents involving persons with mental illness; 1-22: www.lexipol.com.
16. Morabito MS and Socia KM (2015). Is dangerousness a myth: Injuries and police encounters with people with mental illness. Criminology and Public Policy, 14 (2):253-276.
17. Brave M (June 2020). Law enforcement use of force standards, degrees of certainty, and scientific probabilities. Government Liability, 24-30.
18. The International Association of Chiefs of Police (July 2020). National consensus policy and discussion paper on use of force. 1-15: www.theiacp.org/resources/document/national-consensus-discussion-paper-on-use-of-force-and-consensus-policy.
19. Georgia Association Chiefs of Police Legislative Platform: 2021 Legislative Platform and Priorities; The Georgia Police Chief, (Spring Edition, 2021): 36-38.
20. Ross DL (2006). Administrative implications. In Ross, DL and Chan, TC (Eds.) Sudden deaths in custody, Chapter 12; 203-228, Humana Press.
21. The International Association of Chief of Police (August 2018). Responding to persons experiencing a mental health crisis; 1-5: www.theiacp.org/policycenter.
22. City of Champaign, IL Police Department (November 2009). Excited delirium response protocol; 1-3: www.aele.org/delirium/champaign_police_protocol.pdf.
23. The Royal College of Emergency Medicine (April 2019). Guidelines for the management of excited delirium/acute behavioral disturbance; 1-16: www.rcem.ac.uk/docs/College%20Guideline.
24. Vilke GM, Payne-James J, and Karch SB (2011). Excited delirium syndrome (ExDS: Redefining an old diagnosis. Journal of Forensic and Legal Medicine; 1-5.
25. Vilke GM, Bozeman WP, Dawes DM, DeMers G, and Wilson MP (2012). Excited delirium syndrome: Treatment options and considerations. Journal of Forensic and Legal Medicine; 1-5.
26. Nakajima Y and Vilke GM (2016). Use of force in the prehospital environment. In S. Zeller, KD Nordstrom and MP Wilson (Eds.), The diagnosis and management of agitation, Chapter 12; 173-188, Cambridge University Press, UK.
27. Ho JD, Dawes DM, Nelson RS, Lundin EJ, et al. (2010). Acidosis and catecholamine evaluation following simulated law enforcement use of force encounters. Journal of Academy of Emergency Medicine; 60-68.
28. Griffin JD (Fall Edition, 2020). First aid in law enforcement. The Georgia Police Chief; 32-34.
29. Ross, DL (June 2020). Prone restraint webinar, On Demand, Americans for Effective Law Enforcement: www.aele.org/aele-webinars.html.
30. Institute of Prevention of In-Custody Deaths (IPICD) (May 2021). Webinars: Agonal Breathing; Spit Mask: www.ipicd.com/online-training.html#/.
31. Police Executive Research Forum (2017). Integrating communications, information, and tactics (ICAT): www.policeforum.org/icat-training-guide-materials.
32. Nahmod S (April 2012). The long winding road from Monroe to Connick. Scholarly Commons @ IIT Chicago-Kent College of Law; 1-21.