Deputies at the Brevard County Jail appeared to have violated at least 14 sheriff’s office policies and procedures in their handling of a U.S. Army combat veteran who died in custody last December, FLORIDA TODAY has found.

Within two hours of his arrival at Brevard County Jail last December, Gregory Lloyd Edwards was rushed to Rockledge Regional Medical Center by Brevard County Fire Rescue with no pulse and not breathing. He was resuscitated and put on life support, but was pronounced dead the next day. The Brevard County medical examiner's office ruled the manner of death an accident.

Investigation reveals 14 sheriff's policy violations by deputies in death at Brevard jail A FLORIDA TODAY investigation into the death of Gregory Lloyd Edwards reveals more than a dozen violations of Brevard County Sheriff's Office policy items. Rob Landers, Bobby Block and Alessandro Marazzi Sassoon, Florida Today

The deputies involved in the incident were all cleared in Edwards’ death when State Attorney Phil Archer ruled on July 1 that the force used to restrain an agitated and restive Edwards hours after his Dec. 9 arrest was “entirely reasonable and justifiable.”

The official narrative from Brevard County Sheriff Office's own investigations of the Edwards case is that a fight broke out between Edwards and corrections deputy corporal Brian Otto during the booking process on Dec 9. The pair fell to the floor, with Edwards ending up on top of Otto, who told investigators he momentarily blacked out when his head hit the ground.

More: Excited delirium: Rare and deadly syndrome or a condition to excuse deaths by police?

According to the BCSO's review, at least seven deputies rushed to Otto's aid, punching and kneeing an allegedly resistant Edwards, pepper spraying him, tasing him six times in 90 seconds, cuffing him, forcing him into a restraint chair, punching him some more, and placing a spit hood over his head, before wheeling him into a cell and leaving him alone and unattended until he was discovered unresponsive and barely breathing nearly 16 minutes later.

Gregory Lloyd Edwards was a US Army veteran combat medic. Courtesy of Kathleen Edwards

After a seven-month investigation, BCSO's Criminal Investigative Services Major Crimes Unit referred their report to the state attorney, who absolved the deputies of any wrongdoing.

In response to questions from FLORIDA TODAY, BCSO spokesman Tod Goodyear provided a statement in which the sheriff's office said Edwards "was an ongoing and continuous threat to citizens, officers and deputies."

"The actions of Mr. Edwards necessitated the response to his resistance with the use of force to gain control of him. After a thorough review of all facts, this use of force was found by the State Attorney to be lawful, appropriate and reasonable," the statement said.

The state attorney's decision was based in part on the Criminal Investigative Services report which did not include the testimony of two officers involved in subduing Edwards, including the deputy who tased him.

A second unpublicized investigation by the BCSO Staff Services Unit — the equivalent of the sheriff department's internal affairs section, which included those testimonies — found that four deputies in the jail had shown failure of leadership during the chain of events that December day.

The second inquiry found specifically that the superior officers involved in the incident — Major Kelly Haman, Lieutenant George Fayson, Sergeant Richard Zimmerman and Field Training Officer Robert Wagner Jr. — had violated a general policy of maintaining "Professional Duty Responsibilities" during and after the incident.

The Staff Services administrative investigation — wrapped up the same day as the state attorney's findings — was obtained by FLORIDA TODAY through a public records request.

A separate thorough review by FLORIDA TODAY and an independent criminologist of Brevard County Sheriff’s Office’s policy manual, alongside the agency's two reports and BCSO audio recordings of interviews with jail staff, reveals that deputies appeared to have disregarded at least 13 more of their own policies in handling Edwards than were identified by the Staff Services investigation.

Those policies deal mainly with the requirement that inmates must receive medical attention by trained medical staff after they are pepper sprayed or tased or placed in the restraint chair.

According to the BSCO's own investigations and timelines of the incident, Edwards did not receive any medical attention from a nurse until after he was found unresponsive in his cell, and not when he was first secured in the restraint chair, or at other specific times when policy required medical staff to check his condition.

The apparent policy breaches could be grounds for a civil case or a federal civil rights lawsuit against the Sheriff's Office, according to George Kirkham, a law enforcement expert who reviewed the Edwards case.

"These are all violations of 42 USC 1983, the federal civil rights act," said Kirkham, a former Florida police officer and highly commended Florida State University criminology professor.

Kirkham, a consultant and instructor to dozens of law enforcement agencies, was provided with the Edwards investigation case file and the specific BCSO policies by FLORIDA TODAY to independently assess the circumstances that led to Edwards death. Upon review, Kirkham called the BCSO's handling of Edwards — especially the lack of medical attention — "outrageous."

More: Brevard community leaders demand answers about US combat veteran's death in custody

In the BCSO written response to FLORIDA TODAY, the sheriff's office conceded there were violations of policies and procedures concerning the safe restraint and use of force against Edwards, but argued these were necessary because he was violently resisting law enforcement officers.

"The policy violations you allude to were directly the result of jail personnel having to respond to the extremely violent and aggressive resistance by Mr. Edwards," it reads, adding that, "Given the findings of the Brevard County Medical Examiner, our agency is absolutely confident that none of the policy violations found in the policy review played a role in Mr. Edwards’ death."

It also says that, "The four deputies who were found to have committed policy violations received Formal Letters of Reprimand, however it is very clear and evident that the deputies’ response to resistance actions were necessitated by Mr. Edwards’ violent attack on a Corrections Deputy and the subsequent efforts to control him."

State Attorney Phil Archer's spokesman, Todd Brown, said the office had no further comment on the case beyond his findings.

"With the complete investigative record having been made public, the criminal inquiry concluded, and our findings announced, we believe a continued debate offers no greater insight," he wrote in an email.

Archer released the Major Crimes unit investigation report and praised the jail deputies in a July 1 letter to BCSO investigator Jennifer Straight, copied to Sheriff Ivey.

“I further commend the efforts of the deputies and staff at the jail in the actions they took in attending to Mr. Edwards after it became apparent he was in distress,” Archer wrote.

Brevard Medical Examiner Dr. Sajid Qaiser concluded Edwards died of excited delirium, a rare and controversial condition often linked to use of illegal stimulant drugs like methamphetamine, and violence involving law enforcement officers. But the autopsy conclusions have been called into question by Dr. Stephen J Nelson, the chair of the Florida Medical Examiners Commission.

The disconnect between the department’s policies, the information uncovered in the BCSO investigations, the medical examiner's conclusions and Archer’s findings raise serious questions about the lack of accountability for Edwards’ death.

A restraint chair similar to that used on Gregory Lloyd Edwards BCSO

An Army vet with PTSD

Edwards was a 38-year-old Kosovo and Iraq war vet diagnosed with post-traumatic stress disorder and was undergoing treatment.

On the morning of Dec. 9, 2018, he was at the West Melbourne Walmart with his pregnant wife and toddler, when, in an apparent agitated state related to his PTSD, he climbed into a truck being loaded with Christmas donations and allegedly assaulted a man. Edwards was restrained and arrested by West Melbourne police, who recorded his veteran status and took a mental health history from his wife, also an Army veteran.

A West Melbourne police officer, Kevin Krukoski, delivered Edwards to the jail shortly after 1 p.m. Krukoski filed information about Edwards' military service, the circumstances of his arrest, and mental health concerns at the jail. Edwards was delivered with completed Baker Act paperwork. When an individual is Baker Acted they can be provided with emergency services and placed in temporary detention for a mental health evaluation voluntarily, or if required, involuntarily.

While deputies have some basic training in recognizing mental health issues, Armor Correctional, the contractor that provides the jail with medical staff, told FLORIDA TODAY it is not contracted to provide mental health services to the Brevard Jail, and that none of the nurses employed at the jail at the time of the incident had psychiatric training.

Kathleen Edwards in her Grant home, a tapestry with her husband's photo on it hangs on the wall behind her. She is holding the flag given to her at her husband's funeral. MALCOLM DENEMARK/FLORIDA TODAY

No record indicates a mental health evaluation took place at any time Edwards was at the jail, from the moment he arrived to immediately after he was subdued and restrained, as required by BCSO policy.

Before Edwards even arrived at the jail, deputies were aware of his agitated state from reports called into them from West Melbourne police.

Deputies described Edwards as "uncooperative" at the time of his booking.

The BCSO statement to FLORIDA TODAY described the entire interaction with Edwards as fraught, noting, "approximately three hours and ten minutes of continued unlawful, aggressive physical exertion in an attempt to attack, resist and defeat restraint efforts." But video of Edwards' transport from Walmart to the jail shows him sitting in the back of the patrol car, for the most part, peacefully. In interviews with BCSO investigators, deputies testified that Edwards was alternating between bouts of calm and agitation just prior to being taken out of his cell to be booked.

Video of the incident was captured within the Brevard County Jail but has been exempted from public disclosure by the State Attorney’s office and the BCSO.

According to the sheriff's office investigation of the incident, the altercation started when deputy Brian Otto attempted to book Edwards into the jail. Edwards and Otto fell to the floor in struggle. Edwards appeared to throw a punch at Otto's head during the fall and ended up on top of Otto. As many as seven deputies intervened, using "pain compliance techniques," including landing punches and knee strikes to specific areas of the body, applying pepper spray, and then a Taser, before placing Edwards in a restraint chair, punching him some more to better secure him, and then putting a spit hood over his head.

A fine-mesh spit hood similar to that used on Gregory Lloyd Edwards. BCSO

'Provide appropriate medical aid'

According to the BCSO policy and procedures, the deputies' response to Edwards at the jail was problematic almost from the get-go, and their action after Edwards was restrained even more so.

FLORIDA TODAY reviewed all relevant policies related to the jail and the handling of inmates, and compared them to the findings contained in 516 pages of an investigation by the BCSO's Criminal Investigative Services, 52 audio recordings of witnesses, and the 34 pages of the BCSO Staff Services investigation. FLORIDA TODAY obtained the sheriff's office policies and procedures as part of an earlier records request in 2018. All policies and procedures referred to in this article were valid and in effect at the time of Edwards’ detention, though some have since come up for periodic review.

More: Widow of combat veteran who died after fight at Brevard Jail appeals to governor

Sheriff’s office policy is designed to create safeguards around the application of force for both deputies and inmates.

Almost every tool employed by the deputies against an inmate has its own rules and guidelines, and almost all of them require a medical evaluation after their use. BCSO policy states that deputies applying force must “provide for appropriate medical aid to include emergency medical services response after” the “use of less lethal force, whether injury is actual or claimed.”

"He should be checked immediately," Kirkham said, adding that not doing so is "the denial of medical attention."

However, those policies requiring medical attention appear to have been consistently ignored by the deputies until after Edwards had been left alone in his cell and was found unresponsive.

Three separate subsections of the use of force policy related to the use of chemical agents (pepper spray), mechanical restraints, and intermediate weapons (tasers) required Edwards to be placed under observation and medically evaluated.

“After the deployment of a CEW (Taser) on a subject, the arresting deputy will have the subject evaluated and properly cleared by a medical professional, i.e., nurse, EMT, paramedic or medical doctor,” the BCSO CEW policy states.

Show caption Hide caption Thomas Smith, president of Taser International, a US-based manufacturer of law enforcement equipment, displays in Singapore the X26 "electronic control device." The same model... Thomas Smith, president of Taser International, a US-based manufacturer of law enforcement equipment, displays in Singapore the X26 "electronic control device." The same model was used on Gregory Lloyd Edwards shortly before his death in December 2018. ROSLAN RAHMAN, AFP/Getty Images

In the BCSO Staff Services investigation, Agent Joseph Bracey found that the nurse on duty in the booking area, Debora Nadeau, did not medically assess Edwards until 29 minutes after he had first been secured into a restraint chair at the end of the fight, and only then, three minutes after he had been found unresponsive in his cell.

Bracey noted several contradictions in Nadeau's testimony about why she did not immediately evaluate Edwards. She initially said an unspecified deputy told her not to, and later said it was because of an unspecified "rule" in the jail that she is not allowed to assess inmates until deputies tell her it's safe.

"Therefore in the circumstance, she did not medically assess Mr. Edwards because she was not informed it was safe to do so," Bracey wrote in his report.

One of the last measures the deputies took after securing Edwards was placing a spit mask — a fine mesh hood — over his head. The Staff Services investigation found this was not because Edwards was spitting but because the pepper spray had caused him to drool and produce lots of mucus that the deputies did not want to get on themselves.

BSCO Policy states that the provision of medical aid consists of, but is not limited to, “flushing chemical agents from the suspect’s face using water or approved neutralization products.” This was not done before the spit hood was placed on Edwards.

Instead, according to the BCSO investigation, it was only after Edwards was found in his cell unresponsive that nurse Nadeau attended to him. It was only then that the spit hood was removed and the pepper spray wiped from his face with a towel.

Kirkham, an expert in police and corrections agency tactics, said leaving the pepper spray on Edwards' face would have likely left him in "agony," made worse, he continued, because the spit hood causes panic and restricts breathing.

Policy related to the application of a restraint chair also appears to have gone unheeded.

“Medical staff shall check to ensure that the inmate has proper circulation upon placement in the chair” and that it is only “once an inmate is deemed to be secure and has been checked by Medical, he/she shall be placed in the middle of secured cell, isolated from other inmates.”

Bracey's report noted the deputies made the checks, not qualified medical staff.

Gregory Lloyd Edwards is placed in the back of a law enforcement vehicle following his Dec. 9, 2018, arrest in West Melbourne. BCSO

Policy vs. Practice

BCSO policy is very clear that once an inmate is placed in a restraint chair, deputies or medical staff “shall maintain continuous observation during the first 30 minutes to monitor the inmate and adjust restraints as needed.”

"Continuous observation" appears to have never happened.

Staff did observe Edwards with the spit hood over his head intermittently through the window of the jail cell. According to the BCSO investigator’s reporting of events based on timestamps in the jail recording of the incident:

Edwards is secured in the restraint chair at 1:57:22 p.m.

at 1:57:22 p.m. Edwards is left unattended in the holding cell at 2:07:34 p.m.

Corporal Wagner observes Edwards from outside the cell at 2:15:52 p.m.

Corporal Wagner and Nurse Nadeau "view" Edwards from outside the cell at 2:16:04 p.m.

Corporal Wagner sits at his desk with a line of sight through the windows of the booking area and the cell of Edwards at 2:16:48 p.m.

Lieutenant Fayson observes Edwards from outside the cell at 2:17:59 p.m.

Corporal Andrea Mustafa "views" Edwards from outside the cell at 2:22:50 p.m.

Fayson, Wagner and Nadeau "view" Edwards from outside the cell at 2:23:01 p.m., he appears to stop moving one second later. All but the nurse attend to Edwards 16 seconds after that.

Edwards is medically attended to at 2:26:25 p.m.

Between the time deputies secured Edwards in the chair and found him unresponsive in the cell, 25 minutes and 56 seconds elapsed. During that time span, he was alone in the cell for 15 minutes and 44 seconds.

In testimony, Wagner, Nadeau and Fayson made no mention of "observing" or "viewing" Edwards in seeming contradiction with the video timestamps noted in the administrative investigation. In fact, testimony from Mustafa, who only saw Edwards seconds before he was attended to, described the view through the cell window as "not clear" and the glass as "smoky."

"One of the booking techs, D'Agostino came to me and ... says the guy doesn't look right. So we look through and the glass is smoky, and he had a spit mask on. So it was like, it was wasn't clear what we were seeing," Mustafa said in her testimony.

After Edwards was found unconscious, it took another 12 minutes before he was taken to the medical ward — still strapped into the restraint chair. At that point a 911 call was placed. Fire rescue paramedics arrived 11 minutes later, believing they were responding to a call for an injured deputy, not an inmate.

The audio recordings of the 911 call reveal that the jail caller did not know what he was calling for despite the fact that the head nurse told investigators that she had directed the ranking officer in the room to make the call because Edwards was not breathing.

At one point, the paramedic taking the call asked the caller: "What kind of injuries, do you know?"

"I wasn't told that," the caller responded.

The sheriff’s policy is also clear in that it specifically mandates that inmates not be restrained for “longer than necessary” or in any way that causes injury.

Multiple nurses in their testimony to the sheriff’s investigator questioned why an unresponsive Edwards was brought to the medical ward in the restraint chair instead of on a stretcher. A call was made for a stretcher, but deputies decided to bring Edwards to the medical ward in the restraint chair for reasons that are unclear.

"I would have wanted him in the stretcher," Armor Correctional Nurse Yolanda Jones testified.

The chair made doing CPR on Edwards extremely difficult.

When Charge Nurse Ashley Taylor was told Edwards was not breathing, she testified that she ordered him out of the chair to initiate CPR and to that, a deputy responded: "well, he's in the chair."

Taylor persisted. "Get him out, now,” she testified as having told the deputy.

As Edwards was being removed from the chair, Taylor testified, she noticed deep marks on his wrists where the restraints had cut into his skin. Nurse Jones recorded the same.

She also noticed Edwards was bleeding from his nose and was ashen in color. Other nurses testified that Edwards had welts on his face, wasn't blinking, had fixated pupils, and had defecated in the restraint chair.

Charge Nurse Taylor testified that sometime after the paramedics arrived, deputies rushed the nurses to complete their medical reports. Incomplete or erroneous medical reports can lead to legal repercussions and loss of a nursing license.

"The nurses were trying to complete their documentation of the whole incident, we were being rushed to do so. We were told we have two minutes to hurry up and get the charting done and that we needed to get out of his chart," Taylor testified.

One of her nurses, Yolanda Jones, recorded that her file was incomplete because she was pressured by deputies to rush, though she was later able to complete it.

In her own testimony, Jones told a BCSO investigator: "We did try down in medical."

Deputies may have violated 14 sheriff's policy items in death at Brevard jail A FLORIDA TODAY investigation into the death of Gregory Lloyd Edwards at Brevard jail found deputies may have violated 14 policy and procedure items Click to Play Violation 1: Deputy responsibility to provide appropriate medical aid Click to Play Violation 2: Procedure for non-deadly physical force Click to Play Violation 3: Inmate will be examined by medical staff Click to Play Violations 4 & 5: Examination and observation following use of force Click to Play Violation 6: Personnel required for safe application of restraint chair Click to Play Violation 7: Inmate shall have a mental health evaluation Click to Play Violation 8: Nurse shall examine the straps of the restraint chair Click to Play Violations 9 & 10: Continuous observation, medical check at time of placement Click to Play Violations 11 & 12: Medical staff shall check inmate in restraint chair prior to isolation Click to Play Violation 13: Medical clearance after taser use Click to Play Violation 14: Negligence of Professional Duty Responsibilities

The Internal Investigations

Until 2017, Sheriff Wayne Ivey, a former Resident Agent in Charge for the Florida Department of Law Enforcement, or FDLE, would routinely ask the FDLE to lead investigations of deputy involved shootings or deaths in custody.

Then, in 2017, Ivey decided he would no longer bring in third parties to investigate cases involving his deputies. Instead, he announced, his agents would conduct their own internal reviews and hand the findings over to the state attorney's office.

Edwards' widow, Kathleen Edwards, made several unsuccessful appeals to the FDLE and to Gov. Ron De Santis' office to bring in a third party to investigate her husband's case.

Immediately after Edwards was taken to Rockledge Regional Medical Center, the BCSO's Criminal Investigative Service's Major Crimes Unit began interviewing jail staff as well as Kathleen Edwards.

Their investigation report was released by the state attorney's office along with its findings on July 1. The separate BCSO Administrative Investigation report, by Staff Services Unit Agent Joseph Bracey, was quietly signed off on the same day, July 1. That report differs from the Major Crimes probe in a few ways.

Crucially, it contains testimony from deputies involved in the incident who refused to testify for the Major Crimes investigation. It also includes follow-up interviews with involved personnel. While it thoroughly reviews the application of force, it defers to the state attorney's decision clearing the deputies of any wrong-doing.

Brevard County Jail FILE

Instead, Bracey's report considers whether deputies involved violated two provisions of BCSO Professional Standards Policy. In one instance, it clears all deputies of violating a general policy that demands deputies follow federal and state laws, local ordinances, BCSO regulations and orders from superior officers. In the second instance, it finds the four superior officers had violated a general policy of maintaining "Professional Duty Responsibilities."

The investigation identifies "deficiencies in duties and responsibilities" for Haman, Fayson and Zimmerman over a failure to create a log for the use of a restraint chair as mandated by policy.

"Specifically, a distinct lack of direction and communication provided to documentation procedures," it reads, noting failures to maintain situational awareness, and a dereliction of their responsibility overall to "provide leadership direction and guidance."

It reprimands Wagner Jr. for having "failed to establish, secure and maintain direction and control of the scene and witnesses."

Bracey reported that Wagner directed an inmate to clean the jail cell where Edwards had been detained, throwing the spit hood — evidence — that had been placed over Edwards' head in the trash.

Additionally "involved supervisors directed involved employees, potential witnesses, to leave the Jail Complex to conduct other duties, rather than assigning uninvolved personnel."

According to the BCSO, the four deputies cited by the internal investigation received "Formal Letters of Reprimand" in response to Bracey's findings.

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It is unclear why Bracey did not address the deputies' failure to provide timely medical attention to Edwards. Several times in the report, Bracey reports the deputies describing ways of doing things in the jail that appear to be at odds with BCSO policy, such as when a deputy tells him that if an inmate is pepper sprayed and calms down, they might let the inmate shower, or they might wipe off the chemical, but if not, decontamination needs to wait.

Kirkham said the policy violations in the Edwards case reveal a larger problem plaguing law enforcement — that of policy versus practice.

"When the sheriff circles the wagons after something like this, instead of saying 'boys, you've done wrong' and saying: these are our policies, and handing out discipline, and retraining, and make sure it doesn't happen again," Kirkham says that those policies become "a nullity, a nonexistent entity."

"They established by inaction here, what is a de facto custom and practice, which says that 'Hey, you know, we know we got these regulations, guys, but that's not really — wink wink, nod nod — That's not really what we do,'" he said.

Alessandro Marazzi Sassoon is a watchdog reporter at FLORIDA TODAY.

Contact him at 321-355-8144, or asassoon@floridatoday.com. Twitter: @alemzs