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The Milwaukee County medical examiner's office has revised its ruling on the death of Derek Williams, who died in Milwaukee police custody in July 2011, from natural to homicide, according to the district attorney's office.

The decision came after the Journal Sentinel alerted an assistant medical examiner to newly released records - including a video of a suffocating Williams pleading for help from the back of a squad car - and also made him aware of a national expert who said Williams, 22, did not die naturally of sickle cell crisis.

In making his initial determination of natural death more than a year ago, Assistant Medical Examiner Christopher Poulos did not review all of the police reports or a squad video recently obtained by the newspaper. The video shows a handcuffed Williams, his eyes rolled back, gasping for breath and begging for help in the back seat of a Milwaukee police car as officers ignore his pleas. The police reports include key details about Williams' arrest that the medical examiner didn't know.

As a result of the new ruling, Milwaukee County District Attorney John Chisholm is reopening his investigation into whether criminal charges are warranted against any of the officers involved.

Chisholm, the Police Department and the Fire and Police Commission previously had cleared the officers of wrongdoing, largely based on the medical examiner's earlier ruling of natural death.

"We're going to revisit it. Absolutely," Chisholm said. "The medical examiners are our experts in these cases. Without any question, we place a tremendous amount of weight in their determination. Any time they revisit one of their determinations, we really take that seriously."

Chisholm emphasized, however, that the revised finding does not mean a crime was committed. Homicide in medical examiners' parlance means "death at the hands of another." In contrast, the crime of homicide requires prosecutors to prove intent to kill, reckless disregard for life or negligent disregard for life while operating a firearm or a vehicle.

In a statement, Milwaukee police Chief Edward Flynn said he did not expect any officers to be criminally charged as a result of the new ruling.

"This second report contains no information that was not in the first report, nor does it present any new objective facts," the statement says.

In the video, which the paper initially requested last November, Williams struggles to breathe for seven minutes, 45 seconds, then slumps over, unconscious.

An officer then checks his pulse, props him up in the seat and walks to a nearby supervisor's car. Finding no one there, the officer returns and starts CPR as a different officer calls for medical assistance. Police and paramedics continue CPR for more than 45 minutes before Williams is declared dead.

Along with Chisholm, Milwaukee Fire and Police Commission Executive Director Michael Tobin and internal affairs Lt. Alfonso Morales viewed the video months ago and determined officers had done nothing wrong, despite department rules requiring police to call for help immediately "if medical treatment becomes necessary."

The Police Department's Standard Operating Procedures go on to state: "It cannot be overemphasized that members shall continually monitor and remain cognizant of the condition of a person in custody, especially when he/she is in restraints. The arrestee may encounter immediate or delayed physical reactions that may be triggered by the change in physical or environmental factors. Therefore, caution and awareness on the part of the officer is constantly required."

Flynn agreed with Morales' conclusion that the officers did not violate department rules or the law.

Milwaukee police spokeswoman Anne E. Schwartz would not answer questions Friday. Via email, she noted that the department has instituted new training on recognizing and responding to medical distress, including sickle cell crisis, in prisoners.

Tobin said he would review the matter in light of the medical examiner's revised findings.

Neither the two officers who arrested Williams nor the two officers who took turns sitting in the squad car while Williams was in back responded to email requests for interviews.

Poulos re-examined Williams' case after the Journal Sentinel informed him that Werner U. Spitz, a forensic pathologist and one of the nation's leading experts on death investigation, believed the death was a homicide.

Spitz reviewed the case at the newspaper's request . Poulos said in March that he used Spitz's work on sickle cell crisis as a resource in determining how Williams died.

"Is this a natural death? No. This is not a natural death," Spitz told the Journal Sentinel.

Spitz said that while sickle cell crisis likely occurred, it was caused by an officer applying pressure to Williams' back - and perhaps his neck - while he was facedown on the ground.

"This officer didn't have the intention of killing him, but that doesn't mean this kind of restraint should be performed," Spitz said.

Spitz is co-author of the book "Medicolegal Investigation of Death," considered the medical examiners' bible. In addition to evaluating Poulos' autopsy, he reviewed the video and police reports, which were released to the newspaper under a state open records law request.

The newspaper first requested the public records in November 2011. The department released the police reports in June and the video last week.

Williams' loved ones wanted the video to be turned over to the newspaper and made available for the public to see, according to attorney Jonathan Safran, who represents Williams' long-term girlfriend - with whom he had three young children - and Williams' father.

The two are very upset that officers said Williams was breathing just fine and playing games, according to Safran.

"(Williams' girlfriend and father) believe that it was obvious that he could not breathe, and they think it is important for others to see and hear the video and draw their own conclusions," Safran said. "They are devastated by the depiction of what happened to Derek."

The video does not show Williams being arrested or placed in the squad car.

Poulos' initial autopsy report, written in August 2011, includes this note: "Based on the information at the time of this report, the decedent's interaction with police officers included a chase (running) and no physical altercation; therefore, the manner of death is described as natural."

The newly released records tell a different story.

Williams, who had gotten out of jail earlier in the day after being arrested on municipal warrants for loitering, vandalism and assault, fled from police after attempting to rob a couple near the intersection of N. Holton and E. Center streets, according to the reports. He was sweating profusely when police found him hiding behind an overturned card table. Officer Richard M. Ticcioni pulled him out. Ticcioni said he believed rookie Officer Patrick Coe helped him. Ticcioni "ended up on top of Williams with the suspect facing down," according to the report of Milwaukee police Detective Luke O'Day, who interviewed Ticcioni.

Williams, his hands cuffed behind him, repeatedly told officers he couldn't breathe for at least 15 minutes between the time of his arrest and his death, according to records. He first made the complaint as he lay facedown, Ticcioni pressing a knee across his back, O'Day's report says.

"As soon as he released pressure, Williams began squirming, as if trying to break free, and reached around his right side to his right waistband (while still in handcuffs)," according to the report. Ticcioni worried that Williams was trying to grab a gun and "reapplied pressure with his right knee to prevent any further movement from the suspect," the report says.

Officers then searched Williams. No gun was found.

They got him to his feet, and "Williams immediately went limp," the report says. Ticcioni "laid him on the ground on his back and observed that he was breathing hard."

"He felt Williams was playing games and directed him to stop messing around," the report says.

A few minutes later, as officers Ticcioni and Coe were helping Williams walk toward the car, Coe left Williams' side to move a "for sale" sign that was blocking the sidewalk. When he did, Williams "pulled forward and fell face forward into the grass," the report says.

Ticcioni believed Williams was dragging his feet to make it difficult for the officers to get him to the waiting squad car, the report says.

Once locked in the back seat, Williams continued to say he could not breathe and asked officers to call him an ambulance, according to the squad video and a summary of the internal investigation. Officers Jeffrey Cline and Jason Bleichwehl, who can be heard talking on the recording, told internal investigators they did not hear Williams ask for an ambulance, the summary says.

Poulos declined to answer questions Friday.

In March, he told the newspaper he relied on officer accounts that there was no scuffle and on Spitz's book when he ruled Williams' death natural and due to sickle cell crisis.

Poulos misinterpreted the book in making that decision, according to Spitz.

Sickle cell crisis has been the subject of debate in the medical community when it occurs in people such as Williams, who had the genetic marker known as sickle cell trait, but not the disease itself. Sickle cell crisis results when red blood cells suddenly become misshapen, or sickle, blocking blood vessels and preventing oxygen from being carried throughout the body.

Doctors at the National Institutes of Health say people with only the trait cannot die of sickle cell crisis.

Pathologists - including Spitz - counter that it can happen in rare cases.

Sickle cell crisis is caused by oxygen deprivation, Spitz said, and he believes the oxygen deprivation that led to Williams' death occurred when Ticcioni held Williams facedown on the ground and forced his knee into Williams' back.

Putting pressure on someone's back not only stops the lungs from expanding, it also compresses the abdominal organs toward the diaphragm, further restricting breathing, Spitz said. What's more, even people who do not have the sickle cell trait can suffocate and die if they are restrained in that manner, he said.

"If you compress the chest, you cannot breathe. If you cannot breathe, you have a problem," he said. "The whole procedure of arresting somebody by causing them to be asphyxiated is not what should be done."

Officers often mistake the struggle to breathe for an attempt to resist arrest, so they use more force or apply a chokehold, worsening the problem, Spitz said.

There is no mention of a chokehold in any of the reports.

But a cracked hyoid bone in Williams' neck - revealed during the autopsy - is an indication that one of the officers may have put him in a chokehold, Spitz said.

"The hyoid bone fracture is not necessarily harmful, but it indicates with 99% certainty that some force was applied to the area," he said.

It takes tremendous pressure to break the hyoid bone. The injury occurs in only one-third of homicides by strangulation, according to the Journal of Forensic Sciences.

Poulos had attributed the cracked hyoid bone to medical intervention during resuscitation. Spitz said the possibility of that is so remote it should not be considered unless the investigation conclusively proves Williams' neck was not compressed by police restraining him.

"In the absence of another explanation, I think it was done during restraint rather than CPR or intubation," Spitz said. "Under the circumstances of this and from what I've seen, everything in my view seems to suggest a neck hold."

Police on the scene and those who investigated afterward reached another flawed conclusion when they determined that Williams must be breathing OK because he could talk, according to Spitz.

Passing enough air over the vocal cords to speak doesn't mean someone is breathing normally - especially if they are saying they cannot breathe, he said.

If authorities would have taken Williams seriously and gotten him oxygen quickly, he could have survived, Spitz said.

"If they did what they were taught in the Police Academy, maybe that should be changed," he said.

Attorney Robin Shellow, who represents Williams' mother, said anyone trained in CPR, including the officers at the scene, should have known he was in trouble.

"Any layperson observing Derek for more than a nanosecond would have realized he was in medical distress," she said. "The police acknowledge they heard his cries for help. They acknowledge that they heard Derek's words that he could not breathe. The police acknowledge they saw him writhing in the back of the squad car and gasping for air. Why let him suffer for so long until his heart finally stopped?"

It isn't fair to expect police to react the same as average citizens, according to Chisholm. Anyone who works in law enforcement knows suspects often pretend they are sick or hurt in order to avoid being arrested, he said.

"If 99 times out of 100, someone is essentially faking, and the signs of acute emergency mimic that behavior, you have to take it as what's reasonable from an officer's perspective," he said.

The same is true when describing the use of force or a struggle, Chisholm said. What police officers consider normal may not seem that way to people who don't witness arrests every day, he said.

In June, after the Fire and Police Commission review, Tobin recommended that the Police Department consider training on the topic of sickle cell crisis.

As a result of that recommendation, the department has added a component to its CPR training that addresses responding to medical distress and sickle cell crisis, Schwartz said in an email. It will be presented at the academy for the current recruit class. Officers already on the job will receive the training at their next in-service.

Tobin also proposed that the Police Department complete its internal reviews more quickly.

In response to that recommendation, the department last week created a critical incident review board, which will respond to "incidents involving Department members that result in great bodily harm or death, or injury caused by a police member's use of a firearm," according to a newly adopted standard operating procedure.

Schwartz said the review board will provide "a new level of improved and thorough review for critical incidents."

"It also provides for independent participation and review of the process," she said in a statement.

The review board's membership will not include anyone outside the Police Department. All members will be selected by Flynn, and an assistant chief will oversee it. Board reports and recommendations will be presented to Flynn and Tobin, and whether to implement them will be solely up to Flynn.

In addition, Tobin - an attorney and former police officer - now is paged by a dispatcher any time a critical incident occurs, and either he or a Fire and Police Commission investigator responds to the scene of such incidents.

Safran, the attorney who represents Williams' girlfriend, is considering a civil suit on behalf of Williams' three children, ages 4, 3 and 1. Safran also plans to ask the U.S. attorney's office to review the case.

Safran said he is pleased the medical examiner revised his findings, but questions remain .

"The family and I have significant concerns with the actions of police officers, both at the time of Mr. Williams' arrest and while he was gasping for air in the back of the police squad car," Safran said.

"The issues raised in this case support our office's ongoing concerns that in situations where there are claims of police misconduct - especially crimes such as excessive force, or where there is a death or substantial injury claimed due to police actions - that an outside agency might be more effective and impartial in conducting an investigation," he said.

***

Fund established

A memorial fund is being established to care for Williams' three children, ages 4, 3 and 1.

Donations will be accepted beginning Monday at the offices of their attorneys, Samster, Konkel and Safran, located at Riverfront Plaza, Suite 405, 1110 N. Old World 3rd St., Milwaukee, WI 53203. Checks should be made payable to the Derek M. Williams Jr. Children's Memorial Fund.

Whom to contact

To share your thoughts on the death of Derek Williams, contact:

Milwaukee Mayor Tom Barrett: (414) 286-2200; mayor@milwaukee.gov

Fire and Police Commission Executive Director Michael Tobin: (414) 286-5000; fpc@milwaukee.gov

Milwaukee police Chief Edward Flynn: (414) 933-4444

Milwaukee Common Council: (414) 286-2221; or visit Milwaukee.gov/CommonCouncil for a list of city aldermen and their email addresses.