A report from the Tucson Police Department is revealing new details about the death of Carlos Adrian Ingram-Lopez while in TPD custody in April.
The police department began its investigation into the incident hours after it happened on April 21.
Nearly two months later, on June 19, the department finished its report and handed it off to TPD Chief Chris Magnus.
After a news conference about the incident Wednesday, TPD released the full report to members of the news media.
TIMELINE: What happened after Carlos Ingram-Lopez died while in TPD custody
The report recommends termination for officers Samuel Routledge, Ryan Starbuck, and Jonathan Jackson, who had resigned the day before the investigation was completed.
The discipline report focuses on how officers are supposed to treat someone in a state of “excited delirium," how it greatly increased the risk of dangerous physical distress and how the three officers failed to meet their standards and training.
The report draws a number of conclusions about the officers involved in the incident. It says:
- The initial report of Ingram-Lopez's behavior should have prepared the officers to deal with excited delirium before they even saw him.
- Ingram-Lopez's behavior at the scene made excited delirium very clear.
- The report documents dates of when the officers had training on excited delirium at the academy and in other training sessions after that.
- Excited delirium and the likelihood of drug intake make overheating and rapid heartbeat something officers should anticipate.
- The fact that he was calling for water confirms they should have been more aware of his physical distress.
- The officers were trained on, and should have been alert to, signs of breathing trouble, like wheezing, and simply saying “I can’t breathe." Ingram-Lopez did both.
- The officers had been trained on the “recovery position” designed to reduce physical distress on a restrained suspect.
- One of the officers who arrived later said within 15 seconds, “Shouldn’t he be in the recovery position?” That officer is not being disciplined.
- The officers put a “spit sock” over Ingram-Lopez's face because of his choking and clearing his throat made them fear he would spit and spread COVID-19. The spit sock was available to officers even before the COVID outbreak.
- While officers did not use prohibited methods like neck holds, they noted Ingram-Lopez was a large man and one of the officers kneeled on his back for a sustained period.
- Officer Jonathan Jackson was Lead Police Officer -- slightly more senior than the other officers who first arrived at the scene. He was expected to take command and organize the other officers. The report says he failed to command adequately and organize the police response.
- Other officers either reacted appropriately or were with the grandmother, where they were not well aware of what was happening with Ingram-Lopez.
- Overall, the report concluded the officers ignored their training and were unaware or indifferent to Ingram-Lopez's situation and physical distress.
Click here to read TPD's full report.