OKLAHOMA CITY (AP) — Oklahoma investigators recommended more training for the state's execution team Thursday after finding that, out of a sense of modesty, no one monitored an intravenous line that had been placed in the groin of an inmate who writhed and groaned during a lengthy execution.
Clayton Lockett, 38, died 43 minutes after the first drug was administered April 29. Gov. Mary Fallin ordered the state Department of Public Safety to review the execution, as most typically take 10-15 minutes.
In the report released Thursday, the agency said a physician with 15 years' experience and a 40-year medical technician who had worked nearly all other Oklahoma executions failed to place Lockett's IV line properly. Investigators also faulted prison Warden Anita Trammell for ordering that the insertion point be covered up because the drugs were administered near his genitals.
The medical team put the IV in the groin after failing to find suitable veins in his arms, legs, neck and feet, the report said. When it became apparent the execution wasn't progressing as normal, the execution team pulled back a sheet and noticed a swelling larger than a golf ball near the injection site.
"Warden Trammell acknowledged it would be her normal duty to observe an IV insertion point for problems" while a physician would monitor others, the report said. "This investigation found that neither of these observations occurred, which led to the issue being discovered several minutes after the execution began."
Fallin had no immediate comment on the report, but scheduled an afternoon news conference. The prison system said it was already at work reviewing protocols ahead of an execution set for Nov. 13.
Oklahoma used the sedative midazolam for the first time in Lockett's execution, and DPS Commission Michael Thompson said at a news conference Thursday that all three of the drugs — midazolam, vercuronium bromide and potassium chloride — worked as planned.
"The drugs worked," he said. "At the end of the day ... the drugs did what they were designed to do.
"Are there some things that need to be improved? Absolutely."
Thompson referred questions about the timetable for implementing the report's recommendations to the corrections department, which said it will discuss next week.
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.
But Oklahoma's review didn't find fault with midazolam or other drugs, instead noting the IV troubles made it difficult to determine the drugs' effectiveness.
Lockett, 38, 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 Thursday 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 left real victims in his wake. He shot a 19-year-old girl ... and buried her while she was still alive. That's cruel."
Lockett died behind a shuttered curtain 43 minutes after his execution began.
State prisons director Robert Patton, who had halted the execution, had said the inmate died of a heart attack, but autopsy results released last week said he died from the drugs. The autopsy did not explain why the execution took so long or why Lockett writhed.
Prison officials previously said Lockett was combative in his cell on the morning of his execution and that he may have been intentionally dehydrated himself to make it more difficult for the IV to be placed. But the report said Lockett had no signs of dehydration at the time of his death, that his veins were in good or acceptable condition and that self-inflicted cuts on his arms shouldn't have affected IV access.
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 DPS 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.
Three executions, including Warner's, have been set in Oklahoma for November and December.