A doctor and a paramedic failed nearly a dozen times to place an IV during an Oklahoma inmate's execution and were unprepared for how to proceed once the line they secured to deliver a lethal injection began leaking drugs, a report said on Thursday.
The state had placed additional pressure on prison officials to complete the April execution of murderer Clayton Lockett by making the unusual decision to schedule another execution for just after when Lockett's was to be finished, the report from the Oklahoma Department of Public Safety said.
"After it was determined that problems were present during Lockett's execution, personnel involved with the execution were unaware of how to proceed due to the lack of policies and/or protocols in place at that time," it said.
Lockett's execution was halted about 15 minutes after it started due to the IV problems. He died as a result of administered drugs absorbed in his tissue, the report said.
The second execution never took place. No other executions have been held in Oklahoma since then, and the state is facing lawsuits concerning its execution protocols and the combination of chemicals it uses.
Before Lockett's execution, prison medical officials "concluded his veins were 'good' and acceptable for IV access," the report said.
Once in the chamber, the paramedic and the doctor tried to place lines in his arm, jugular vein and a foot before landing one in his groin.
After the drugs were administered, those in the death chamber saw blood and a clear liquid leak onto a cloth covering the groin area from and discovered an area of swelling nearly the size of a tennis ball at the IV site, it said.
The execution was halted and a curtain drawn to block the view of witnesses, who said Lockett had been twisting on the gurney. The doctor and prison officials debated what to do with the inmate, who died about 45 minutes after the procedure began.
"There was conversation inside the chamber about administering life-saving measures to Lockett, including transporting him to the emergency room, but no order was given, the report said.
Lockett, 38, was convicted of first-degree murder, rape, kidnapping and robbery for a 1999 crime spree with two co-defendants. Teenager Stephanie Nieman was shot and buried alive in a shallow grave, where she eventually died.
Department of Public Safety Commissioner Michael Thompson told a news conference, "despite the complications, the drugs worked." He recommended changes that included having more medical equipment on hand, leaving the IV area uncovered and better training.
Dale Baich, an attorney in a group representing Oklahoma death row inmates said: "The report does not address accountability. It protects the chain of command."