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LaWall won't charge TPD officers in April death of Carlos Ingram-Lopez

Restrained man's death one of pair that Tucson police withheld from public notice

Three former Tucson cops won't face criminal charges in the April death of Carlos Adrian Ingram-Lopez, who died while being held down as he begged for water and told them he couldn't breathe.

Pima County Attorney Barbara LaWall announced Monday afternoon that her office did not find enough evidence to bring charges against Samuel Routledge, Ryan Starbuck and Jonathan Jackson, who resigned in June after a delayed Tucson Police Department internal investigation determined they should be fired.

TPD also referred the case to LaWall's office for possible criminal prosecution of the three ex-officers. A statement from the Pima County Attorney's Office said that the "crimes considered are assault, unlawful imprisonment, and reckless manslaughter or negligent homicide."

The county attorney, who is stepping down from her office after the November election, said that there was not enough evidence to convince a jury beyond a reasonable doubt that the officers' actions caused Ingram-Lopez's death.

LaWall and her staff noted that the officers violated several TPD General Orders, and that "through their training, each of the officers should have been aware of the potential risk of death" in their actions.

But the county attorney found that "there is insufficient evidence to prove negligent or reckless homicide," and that the officers did not break the law in restraining Ingram-Lopez.

"There is evidence that the officers at the very least failed to perceive the risk of death. Arguably, there is also evidence that they disregarded a known risk that Mr. Ingram-Lopez could die," LaWall's report said. "In order to prove negligent homicide or manslaughter, the State would have to prove beyond a reasonable doubt that the risk the officers ignored or failed to perceive was a 'substantial and unjustifiable risk,' and that disregarding or failing to perceive that risk was a 'gross deviation from what a reasonable person would observe in the situation.'"

LaWall did not indicate that information about the case was presented to a grand jury for review. Her report only discussed the internal decision at the Pima County Attorney's Office.

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Document: LaWall decision to not prosecute in death of Carlos Ingram-Lopez

The April death was not publicly disclosed by TPD for months — it was only after TucsonSentinel.com revealed in June, following an news investigation, that a man had died while in police custody that the department provided any information to the press and public.

The lack of information released in that case, and the March death of Damien Alvarado while he was restrained by Tucson officers, prompted Mayor Regina Romero and the Tucson City Council to mandate that all deaths in TPD custody be disclosed "immediately."

LaWall said she would have no comment on the decision, beyond the document released Monday.

Laura Conover, who is poised to be elected to replace LaWall in November, as the Democratic candidate does not have a general-election opponent, has criticized the Pima County Attorney's Office's handling of the case.

Reading the report by LaWall, "the facts are visceral. The trauma in our community is real," Conover told TucsonSentinel.com on Wednesday evening.

"For certain incidents, I will continue to speak about and encourage the appointment of a wholly independent prosecutor," Conover said. "The system asks the Pima County Attorney's Office to work closely with law enforcement. Therefore, when things go wrong, the community deserves the independence and neutrality of a prosecutor, separate from the County Attorney's Office, who can investigate and indict appropriate criminal charges."

The all-but-certain next top prosecutor said that TPD's participation in the Sentinel Event Review Board that examined the incident was "crucial to moving our system in the right direction."

"The attorney who represents the people must be available as well. The opportunity to ask questions of and be heard by the elected official is sacred. This is my plan," she said, rebuking LaWall for refusing to comment beyond the document.

Ingram-Lopez's daughter and mother have filed notices of claims against the city and the three officers, demanding nearly $50 million between them to settle a potential wrongful death lawsuit.

From the 14-page report, sent Monday as a letter to TPD Chief Chris Magnus:

The fact that the officers did not provide water to Mr. Ingram-Lopez was not a gross deviation because it was not contrary to their training or policy, and there are reasonable explanations for it. Likewise, using a spit hood and placing blankets over Mr. Ingram-Lopez was not a gross deviation because it was not contrary to the officers' training or policy, and there are reasonable explanations for this.

By contrast, the failure of the officers to call for paramedics immediately, and leaving Mr. Ingram-Lopez on his stomach in the prone position with his arms handcuffed behind his back for several minutes without checking on his breathing and attending to him were gross deviations from the standard of care these officers were trained to provide.

Their training was designed specifically to alert officers to a potential risk of death. We must determine whether the officers' omissions and gross deviations from the standard of care under these specific circumstances directly resulted in a risk of death that was both "substantial and unjustifiable." We find that the officers' conduct did result in an unjustifiable risk. The question then becomes whether the risk of death was also "substantial."

There is professional literature that puts the risk of death under these circumstances at 10% or less. Some might consider that level of risk to be substantial - meaning a strong possibility, while others might consider it to be less than substantial - meaning merely a significant or remote possibility. Therefore, we must acknowledge that reasonable minds might differ with respect to this issue making it questionable to conclude that we could prove to a jury beyond a reasonable doubt that the officers disregarded or failed to perceive a "substantial" risk of death to Mr. Ingram-Lopez. However, even assuming the evidence is sufficient to prove the officers failed to recognize that their conduct resulted in a "substantial and unjustifiable" risk of death to Mr. Ingram-Lopez, there is a final element that must be proven as well. That final element is causation.

All homicide crimes, including negligent homicide and reckless manslaughter, require proof that the suspect's conduct actually "caused the death of another person." The State must prove, beyond a reasonable doubt, that but for the officers' conduct through their acts or omissions Mr. Ingram-Lopez would not have died.

Here, there is insufficient evidence that the officers' conduct caused Mr. Ingram-Lopez' death. To the extent there is a suspicion that the officers' conduct may have been a factor resulting in Mr. Ingram-Lopez' death, mere suspicion, however reasonable, is insufficient. There must be proof beyond a reasonable doubt that it was their conduct that caused Mr. Ingram-Lopez' death.

Proof of causation is heavily dependent upon the findings of medical experts. In this case, the experts' findings are inconclusive.

LaWall said her office attempted to interview Dr. Phillip Keen, a former Maricopa County medical examiner who conducted an independent autopsy on behalf of Ingram-Lopez's family. But Keen said he would only consent to an interview with prosecutors if they did not ask him about perjury charges he faced in another case, and then ceased communicating with PCAO, she said.

"Without credible and relatively certain medical testimony tying the cause of death of Mr. Ingram-Lopez to the conduct of the officers, there is insufficient evidence to prove a crime of negligent or reckless homicide," LaWall said in the letter, which was also signed by Chief Deputy County Attorney Amelia Cramer, Chief Trial Counsel Nicol Green, Chief Criminal Deputy CA David Berkman and Deputy County Attorney Rick Unklesbay. "Due to the lack of proof of causation, the Pima County Attorney's Office declines to file criminal charges," they said.

Daughter, mother prepare to sue city, officers

An attorney representing Ingram-Lopez's mother called the decision "incredibly disappointing."

"The family is obviously disappointed, and they're unhappy with the county's decision," Eduardo Coronado said. "They have to consider what's the next action."

Coronado said that he disagreed LaWall, but said that there was "little to do for now." He noted that last Tuesday, he filed a notice of claim on behalf of Iris Lizarraga, Ingram-Lopez's mother, writing that the man death "resulted from the city of Tucson's conduct, through the conduct and actions" of the three police officers.

The claim, which is required under Arizona law before a lawsuit is filed against a government agency, asks for $15 million from the city and $4 milion from each of the three officers to settle the potential legal case.

Other attorneys filed a different notice of claims last month on behalf of Sophie Ingram, Carlos's two-year-old daughter. That potential suit seeks $10 million in damages from the city of Tucson, and $3 million from each of the officers who were directly involved in the incident.

Ingram-Lopez was on cocaine, died when held down by police

Carlos Adrian Ingram-Lopez, 27, died April 21 while being restrained by police, who responded when his grandmother called 911 from her home.

Naked and yelling, he was chased through the house by arriving officers, who charged in yelling "Get on the fucking ground." He ran into the garage, laid down, and was double-handcuffed by police and placed face down on the garage floor, with officers holding him down.

His grandmother, Magdalena Ingram, had called 911 at 1:12 a.m., saying that her grandson was naked, under the influence and going "crazy," a police report filed the day after the incident said.

TPD police report on the April 21 death of Carlos Ingram-Lopez

"Oh my God, oh my God," she had screamed into the phone, it said.

The three officers — Samuel Routledge, Ryan Starbuck and Jonathan Jackson — arrived at the home at 1:20 a.m., the report said.

Ingram-Lopez, who was later found to have a large amount of cocaine in his system, yelled for several minutes after being restrained by the officers, but did not put up any serious struggle against the officers, a police bodycam video showed. (See the raw video below.)

Officers found him already lying on the garage floor when they entered.

"OK, please," he said as they restrained him. He screamed and wailed.

"I will Tase you," an officer said forcefully. One officer fumbled with a pair of handcuffs.

Ingram-Lopez repeatedly asked for water in English and Spanish, called for his "nana," and said "oh shit, I can't breathe." At one point, officers put a "spit sock" over his head.

"Relax," one officer said.

Magdalena Ingram leaned through the door connecting the home and the garage, asking "Officer?"

"Ma'am, get out of here. Go wait inside," an officer said. The woman backed up.

"I'm sorry, I'm sorry," Ingram-Lopez said.

"Relax," an officer said.

"Please give me some water," said the prone man. "Oh, shit, I can't breathe."

"Can I please have some water."

At one point, in response to the her grandson's calls for water, Magdalena Ingram gave a bottle of water to Officer Starbuck, but he did not provide it to the man.

"When he calms down, he can get what he wants," he said, the TPD report said.

Ingram-Lopez was quiet for a few moments, with only the sounds of the police radio captured on the video.

"Just relax, all right," one officer said.

"Can I please have some water... what are you doing?," Ingram-Lopez said. "What are you doing? I want some water. Agua por favor. Please. Please. No. Water. What the fuck?"

TPD internal investigation report into death of Carlos Ingram-Lopez

Ingram-Lopez "showed every sign of being overheated (major symptom of excited delirium)," the TPD internal affairs investigation found. "He repeatedly asked for water, he was naked, and sweating."

The man, who weighed 245 lbs. and was 6'3" tall, began to thrash as one officer lay across his legs and another held down his upper torso. The autopsy report said he had numerous abrasions on his face, forehead, and arms and legs.

One officer, Jonathan Jackson, was the first on the scene and later told investigators that he did not hear Ingram-Lopez ask for water, the TPD report said.

"Get the fuck down," one officer said.

"You're going to get shocked, dude. You're going to get zapped," Routledge told Ingram-Lopez.

Routledge later provided no justification for threatening to use his Taser, investigators said. Routledge had been bitten by a dog while making his way through the house to the garage.

"Instead of deescalating, officers told Mr. Ingram-Lopez to, "Shut the fuck up," the TPD internal affairs document said.

On the concrete floor, the man took heavy breaths.

After several minutes of him yelling incoherently and having spasms under the blanket, officers opened the garage door and covered him with yellow film emergency blankets.

"Chill the fuck down, man," one said.

Medical Examiner's toxicology report on Ingram-Lopez

"We're putting a blanket over you, dude," said an officer. Jackson placed one over Ingram-Lopez's lower torso, and then another was unfolded and Jackson placed it over his upper body, covering his shoulders and his head.

Soon after, Ingram-Lopez, still on his stomach on the ground, began making loud choking sounds.

TPD's executive review of the department's internal investigation of the incident said the three officers "showed complete disregard" for their training, "but most importantly an apparent indifference or inability to recognize an individual in medical distress and take the appropriate action."

According to the toxicology report, Ingram-Lopez had cocaine in his system (628 ng/mL) and an amount of a cocaine metabolite, benzoylecgonine, that would indicate significant recent use (7468 nb/mL).

One of the officers, Starbuck, placed a "spit sock" on Ingram-Lopez's head after he "began making sounds as though he was clearing his throat/airway," the TPD investigation said.

"Nana, oh my God, nana," he yelled.

"Please," the man said, "some water.... por favor...." He began yelling louder, making sounds rather than words.

Routledge continued to hold the man's legs, with Jackson and Starbuck applying pressure to his upper back, each with a knee, another officer observed as he arrived, according to the investigation.

"Multiple officers were on-scene and could have helped control Mr. Ingram-Lopez once he was in the recovery position or in a seated position," the report said.

"No, no, no," the man said, breathing heavily.

He then grew quiet.

One patted Ingram-Lopez on the back. "Are you alive?," an officer asked quietly, about 12 minutes after the man had been restrained.

The man made some small movements.

An officer again patted him on the back, several times.

Another officer who had arrived at the scene asked, "Shouldn't we have him in the recovery position?"

"Is he breathing?," one asked.

"Hey," one said. "Hey. Hey! Hey!," he said, more loudly.

As the officers tried to revive the man, his grandmother asked, "What happened to my grandson?"

"He's not responding," she said.

Another officer, Sgt. Robert Mitchell, who had arrived after the others, told the officers to put Ingram-Lopez on his side

The officers rolled Ingram-Lopez on to his side, about two minutes after his "last audible sound," the investigation said.

Another officer who had arrived shortly after the initial three, Officer Jerin Stoor, told Jackson to request an ambulance.

"He's not very conscious right now," an officer said. "He's not conscious," apparently speaking into his radio to a dispatcher about 13 minutes after Ingram-Lopez was restrained.

The Tucson Fire Department was dispatched at 1:36 a.m.

Ingram-Lopez autopsy report

Outside autopsy conducted by family

The county medical examiner found that the cause of death was "sudden cardiac arrest in the setting of acute cocaine intoxication and physical restraint." Tuesday night, TPD had stated that the death was "ascribed to sudden cardiac arrest, with acute cocaine intoxication and an enlarged heart," not disclosing the finding that "physical restraint" was involved.

As the officers asked that an ambulance be sent, Ingram-Lopez's grandmother stepped into the garage.

"What happened?," she said, craning her neck to see around a parked car. The officers yelled at her to "go back inside." She quietly returned back inside the house.

One of the officers administered a dose of Narcan. "I'm going to do it one more time."

Tucson police and city officials did not reveal the incident until after it was exclusively first reported by TucsonSentinel.com. Three officers who were at the scene resigned the previous week after an internal investigation, which determined that they should be terminated. Internal city sources criticized the delay in releasing any information to the public, with one calling it an attempt at a "white-wash" earlier in the week.

Ingram-Lopez shared a home with his grandmother, and was the father of a toddler-aged daughter.

After the doses of Narcan, the officers again rolled Ingram-Lopez over and dragged him into the driveway, where they began to perform CPR, administering chest compressions. From the video, it's not apparent if they checked his airway. And some point, the handcuffs were removed from the man, and then he was cuffed again in front of his body.

About five minutes later, an ambulance arrived, with an officer using his flashlight to signal the location to the vehicle finding its way through the darkened narrow streets of a single-story townhouse development on the East Side.

Tucson Fire Department personnel vigorously took over the CPR effort.

"It looks like he vomited inside his mask," someone said.

Tucson Fire EMTs tried to resuscitate him with a defibrillator, and inserted an endotracheal tube to try to clear his airway

Carlos Adrian Ingram-Lopez was declared dead at the scene at 2:06 a.m.

He had a body temperature of 101.3 degrees when EMTs examined him at the scene, the autopsy report said.

The spit sock was used after he had been "attempting to open his airway and clear his throat, possibly vomiting (another sign of excited delirium)," the TPD investigative report said. Using a spit sock to contain liquids while keeping someone face down is "contrary to spit sock training," it said, "because any vomit or other material expelled by Mr. Ingram-Lopez would have been deposited in the spit sock and possibly become an airway obstruction."

"The use of blankets to completely cover an individual who was showing signs of overheating and difficulty breathing to provide him dignity was inconsistent with training," it said.

Starbuck had been a certified EMT for 14 years before joining TPD. The internal investigation found that he and Routledge "failed to recognize this call had transitioned to a medical call once Mr. Ingram-Lopez was safe and Mr. Ingram-Lopez was handcuffed. Mr. Ingram-Lopez was naked, sweating, speaking gibberish, hallucinating, using narcotics and showing all the signs of excited delirium. This was never discussed by the officers on scene or considered."

"There were no attempts to develop a plan, which rushed the situation and eliminated opportunities for deescalation," the report said. "Even after Mr. Ingram-Lopez complied with commands they could have stopped and slowed things down, but they did not."

Raw video & June press conference: Magnus & Romero on the death of Carlos Ingram-Lopez in Tucson policy custody

Content warning: This video includes raw body-cam footage of a man dying while being restrained by Tucson police.

Officers dodge firing with resignations

Officers Jonathan Jackson, Samuel Routledge and Ryan Starbuck quit before they could be fired by the department.

The specific policy violations cited in the report's determination that the three officers should be removed from the force were: "212: Failure to Take Appropriate Action," "207: Use of Force (Other)," and "405: Actions on Duty." Those allegations were each found to be sustained by the investigation.

Jackson was the first on the scene, and told investigators that "his thought process was to get this subject detained as quickly as possible and get him to jail," the report said.

The investigation found Jackson had a "complete lack of incident command."

The case, first reported to the public by TucsonSentinel.com, has been referred to the Pima County Attorney's Office for potential prosecution of the officers, Magnus said. The chief also said he has asked the FBI to review the case.

The three handed in their resignations on June 18 — almost two months to the day after a man died while being restrained by cops who responded to a 911 call placed by the man's grandmother.

TPD's internal investigation said that the three officers did not place Ingram-Lopez on his side in the "recovery position" for more than 12 minutes as they restrained him.

A timeline created by a TPD investigator, based on bodycam footage, during the day following the incident found that Ingram-Lopez was handcuffed behind his back and on the ground face down for 12 minutes and 14 seconds.

"I also noted that from the time Ingram-Lopez became unresponsive to when officers noticed him unresponsive was one minute and nineteen seconds," that report said.

The report said that police officers in Arizona have been trained for 20 years to use that position to "reduce the likelihood of serious injury or death" when dealing with individuals who may be experiencing "excited delirium." The three officers had received such training, the report said.

Magnus told reporters in June that it's "important to note there is no indication of malicious intent nor did any of the officers deploy strikes, use chokeholds, or place a knee on Mr. Ingram-Lopez's neck."

Even when pressed by reporters, Magnus refused to comment on what the officers specifically did wrong to deserve being fired, referring questioners to the document produced by the internal investigators.

"In the video, we see a person who is clearly distressed, asking for water, asking for help, asking for his nana," said Romero. "Now we must center the conversation on police accountability and transparency. When officers do not perform as trained, they need to be held accountable."

The TPD internal report says that instead of de-escalating the situation, "they focused on the arrest and missed the significance of the situation."

"There were two very large officers detaining a restrained man in medical crisis, and they did not use the tactics taught to restrain the male properly," the report said.

Whether the three are allowed to remain certified officers, able to be hired by another department, will be determined by state officials at the Arizona Peace Officer Standards and Training Board. TucsonSentinel.com has requested but not yet received any communications between the city and AZPOST.

The Pima County Attorney's Office was advised of the incident on June 11, when an investigator dropped off a copy of the case file for Deputy County Attorney Nicol Green. On June 17, Green met with a TPD investigator, requesting documents and evidence, including TPD's training materials regarding the recovery position, protocols about when to call the department's Mental Health Support Team, training materials on the use of spit socks, and training documents about "positional asphyxiation."

This original news reporting was partly supported by the Brechner Center for Freedom of Information at the University of Florida, which awarded Sentinel Editor Dylan Smith a Brechner Reporting Fellowship to pursue in-depth journalism about government secrecy.

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Carlos Adrian Ingram-Lopez