OKLAHOMA CITY -- Oklahoma turned to a 15-year physician and a medical technician with 40 years' experience to put Clayton Lockett to death, yet his execution still went awry.
Now, investigators are recommending more training for executioners, blaming Lockett's flawed, lengthy lethal injection on April 29 on poor placement of intravenous lines and a warden's decision that modesty was more important than monitoring Lockett for signs of trouble. The three drugs administered were not a factor, the state said.
The findings and recommendations of the governor-requested, state-handled investigation highlight the difficulty that death penalty states face in making sure the people performing a grim medical procedure are properly prepared to see it through.
"Is there some things that need to be improved? Absolutely," Oklahoma Department of Public Safety Commissioner Michael C. Thompson said Thursday after his agency released the findings of its investigation. "We think that the IV was a big issue with the execution."
Out of modesty, no one monitored an intravenous line that had been placed in Lockett's groin before the start of his execution, a job that is the normal duty of Oklahoma State Penitentiary Warden Anita Trammel, who decided to cover Lockett's body -- and the IV -- with a sheet.
"Those involved with the execution stated that they could have noticed the problem earlier if they had been monitoring the insertion site during that time," lead investigator Capt. Jason Holt said.
Lockett, 38, writhed and moaned before he was declared dead 43 minutes after the first drug was administered. Gov. Mary Fallin ordered the review of the execution; most typically take 10 to 15 minutes.
The medical team -- whose experience was revealed for the first time Thursday -- could not find suitable veins in Lockett's arms, legs, neck and feet, leading them to insert it in his groin, the report said. When it became apparent the execution wasn't progressing normally, the execution team pulled back the sheet and noticed a swelling larger than a golf ball near the injection site.
State prisons director Robert Patton began rewriting the state's execution guidelines following Lockett's execution and was receptive to the DPS recommendations, Fallin said Thursday afternoon.
Three executions have been set for November and December, the first on Nov. 13, but Fallin said the recommendations must be implemented first.
"If I am assured as governor that those protocols are in place ... then we can look forward to returning to executions," Fallin said. "But until all of those protocols have been put in place, we won't be having executions."
Corrections spokesman Jerry Massie said Patton had no immediate comment. But Thompson echoed Fallin earlier Thursday: "The last thing we want to do is rush this and have an issue come up where we're not prepared for an execution."
Officials would not comment on a timeline or specifics regarding when they plan to implement the guidelines.
Oklahoma used the sedative midazolam for the first time in Lockett's execution, but Thompson said all three drugs -- midazolam, vercuronium bromide and potassium chloride -- worked as planned.
"At the end of the day, despite the circulation issues that we had, the drugs did what they were designed to do," he said.
Midazolam was also used in lengthy attempts to execute an Ohio inmate in January and an Arizona prisoner last month. Each time, witnesses said the inmates appeared to gasp after their executions began and continued to labor for air before being pronounced dead.
Thompson said no single person was to blame for the foul-ups and no charges are being considered, leading critics to charge that the report does not address accountability.
"It protects the chain of command," said Assistant Federal Public Defender Dale Baich, an attorney who represents 21 death row inmates who have sued the state Department of Corrections to block their executions.
"Once the execution was clearly going wrong, it should have been stopped, but it wasn't," Baich said in a statement. "Whoever allowed the execution to continue needs to be held accountable."
Patton, who had halted the execution, had said Lockett died of a heart attack, but autopsy results released last week said he died from the drugs.
Lockett had been convicted of shooting Stephanie Nieman, 19, with a sawed-off shotgun and watching as two accomplices buried her alive in 1999. Thompson said the victim should not be forgotten while exploring the manner of Lockett's death.
"Victims have rights. They don't get the attention they deserve," Thompson said.
Lockett's execution was to be the first of two held back-to-back on April 29, but the second one for Charles Warner was postponed. The report recommended Oklahoma hold executions at least seven days apart, noting that the prison warden believed that the planned double execution caused "extra stress" for staff members.