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In the aftermath of in-custody deaths, authorities rely on each other’s conclusions — even when those conclusions are flawed — ensuring no one is held accountable when prisoners die. Go to section.

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Derek Williams died gasping for air in the back of a Milwaukee police squad car.

For at least 15 minutes before he died last July, Williams, his hands cuffed behind his back, repeatedly told officers he couldn't breathe, according to the district attorney's office. One officer responded by rubbing Williams' chest. Another opened the car windows.

But no one called an ambulance until Williams lost consciousness - despite a department policy that requires officers to quickly summon medical help for prisoners who need it.

He was 22.

"They wouldn't want someone to do that to their child, so why would they do it to mine?" asked Williams' mother, Sonya Moore. "They just sat back and acted like they didn't have a soul."

Neither the Police Department nor the district attorney's office will release the squad video that depicts Williams' death - although Milwaukee County District Attorney John Chisholm allowed the family to view it. What they saw caused them to question the prosecutor's conclusion that the officers aren't criminally responsible for what happened. They also dispute a ruling by the medical examiner's office that Williams died of natural causes.

The prosecutor, the pathologist and the family agree on only one thing: If someone had called an ambulance sooner, Williams might still be alive.

Chisholm said the department needs to examine what can be done to prevent similar deaths in the future.

"It's not a criminal misconduct question, but it's certainly a relevant training question," he said in an interview with the Journal Sentinel.

An internal police investigation into whether the officers violated department rules remains pending more than seven months later. Those rules require officers to call for help immediately if medical treatment becomes necessary.

"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," according to the department's Standard Operating Procedures. "The arrestee may encounter immediate or delayed physical reactions that may be triggered by the change in physical or environmental factors."

Milwaukee Police Chief Edward Flynn declined to discuss the case. None of the officers involved responded to emailed requests for interviews.

Department spokeswoman Anne E. Schwartz issued a statement that said: "We have nothing to add, as the district attorney and the medical examiner have both made a ruling in this case that determined that the death of Derek Williams was due to a prior medical condition."

But the cause of death cited, 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. Doctors at the National Institutes of Health say people with only the trait cannot die of sickle cell crisis. Pathologists counter that it can happen in rare cases.

Fled from police

Williams had been released from jail on a child-support violation just a few hours before he died, according to his family. When he left home with his girlfriend's father shortly before midnight July 5, the temperature was near 80 degrees.

A letter Chisholm wrote to Flynn explaining why no police officers would be charged details what happened next.

Officers Jeffrey Cline and Zachary Thoms came upon an attempted robbery near the intersection of Holton and E. Center streets around 12:36 a.m. July 6, the letter says. When the suspect - whom officers later determined to be Williams - saw them, he ran. He jumped a chain-link fence, ran through an alley and hid behind a patio table.

He was apprehended by two more officers, Patrick Coe and Richard Ticcioni, the letter says.

"When the officers first approached Williams, they observed he was breathing heavy and sweating, and not immediately compliant with being placed under arrest," the letter says. "However, after turning Williams over onto his stomach and exerting some force onto his shoulders, the officers were able to handcuff Williams and bring him to his feet."

At that time, "Williams did complain that he was having difficulty breathing," the letter says.

An officer rubbed Williams' chest, and Williams "verbally responded appropriately, and appeared to be able to take in oxygen normally and well," the letter says.

Coe and Ticcioni did not use "strong force" against Williams, according to the letter.

They handcuffed Williams and placed him in the back of Cline's squad car, where Williams repeatedly said he could not breathe for about 10 more minutes, the letter says. At one point, Cline rolled down the windows.

After that, Cline left to continue the robbery investigation and Officer Jason Bleichwehl got into the driver's seat, the letter says. Bleichwehl asked Williams a few questions. Williams did not respond and slumped over. About 90 seconds later, Bleichwehl went to check on him and found that he had no pulse. The officer began CPR.

Paramedics were called at 12:59 a.m., 15 minutes after Williams was arrested, according to Chief Deputy District Attorney Kent Lovern, who was called to the scene because Williams' death occurred in police custody.

Autopsy performed

At autopsy, Milwaukee County Assistant Medical Examiner Christopher Poulos found superficial cuts and scratches on Williams' hands, arms, legs, feet, abdomen and back, as well as bruises on his hand, elbow and back, according to the autopsy report. Poulos concluded that the injuries occurred when Williams ran from police and jumped the fence.

"All the injuries could be attributed to the chase," he said in an interview. "I do not have any reports of a scuffle or anything else. Had there been a report of a significant fight, it may have changed how I listed the manner of death." Williams also had a cracked hyoid bone in his neck, according to the autopsy. That type of injury is common in people who have been strangled, but can occur during CPR in rare cases, Poulos said.

"If somebody is manually strangled, or has a boot to the neck or something like that, you would see hemorrhages in the neck, eyes or face," he said. "(In Williams' case), these simply weren't there."

Poulos listed the cause of death as sickle cell crisis, which occurs when red blood cells suddenly become misshapen, or sickle, blocking blood vessels and preventing oxygen from being carried throughout the body.

Williams did not have sickle cell disease, which requires two copies of a genetic mutation, one from each parent.

Rather, he received a gene with the mutation from one parent and a normal gene from the other, which means he could not develop the disease. People such as Williams have what is known as sickle cell trait, making them carriers who could pass the disease to their own children. About one in 12 African-Americans carries the trait, according to the Sickle Cell Association of America.

Doctors at the National Institutes of Health say people with only the trait cannot die of sickle cell crisis, although it's possible the trait may make them more susceptible to other conditions, such as exercise-related death or dehydration.

"If somebody is short of breath and/or having severe pain and they can't move, they are identifying themselves as having an acute illness and you have to call 911," said Harvey Luksenberg of the National Heart, Lung and Blood Institute. "It doesn't matter what the context is. Those symptoms are alarming. These people need to be brought to a hospital, given I.V. fluids and monitored very closely."

Regardless of the cause of death, medical examiners may find sickled cells during an autopsy because the process of dying itself deprives the cells of oxygen and causes them to become deformed, he said.

To pathologists, that is an outdated view, according to Poulos. The book "Medicolegal Investigation of Death," one of the principal texts used by medical examiners, discusses the condition at length, he said.

"It's rare, but in extreme exertion you can get sickling in cases of the trait," Poulos said. "In my opinion it is commonly accepted."

Although Poulos said he is not an expert in the condition or its treatment, he confirmed that it is not always fatal.

"It can be treated," he said.

The police who waited 15 minutes to begin treatment for Williams did not commit a crime because they did not show reckless disregard for his life, Chisholm said.

"The conclusion I believe they drew was he was reasonably out of breath due to running from the police," Chisholm said. "There was no distress other than being upset about being arrested."

The Police Department should learn from Williams' death, instituting training to help officers recognize the signs of sickle cell crisis and respond appropriately, he said.

Schwartz would not say whether the department planned to do so.

Relatives are skeptical

Williams' family suspects the diagnosis of sickle cell crisis is being used to conceal the real reason for his death. They asked Chisholm to convene an inquest to explore the possibility that Williams died due to positional asphyxia caused by the officers' use of force as they pulled him out from under the patio table, placed him on his stomach and handcuffed him.

Positional asphyxia, the inability to breathe due to the position of the body, can be caused by physical restraint, especially if someone is held facedown, according to several studies published since the 1990s.

Correctly identifying positional asphyxia as the cause of death depends on both an autopsy and a thorough death investigation, according to a study published in 2000 in the American Journal of Forensic Medicine and Pathology.

"Pointed interviews with witnesses and participants in the restraint, focusing on the mechanics of the restraint, the length of time involved, and the moment when loss of consciousness occurred, should be conducted soon after the event while memories are still fresh," the article says.

Chisholm said an inquest into Williams' death would not be appropriate because the district attorney's office already has done a thorough investigation and determined that no crime occurred. Under Wisconsin law, the purpose of an inquest is to assist the district attorney in deciding whether or not to file charges, he said.

Chisholm's predecessor, E. Michael McCann, convened inquests into police use-of-force deaths any time the families requested them. He did not consider them an investigative tool, McCann told the Journal Sentinel in 2005. Rather, he considered them a public airing of facts that might bring about policy changes.

When Chisholm took office in 2007, he decided inquests were not the proper forum for investigating deaths in police custody, he said.

Instead, Chisholm or Lovern, his chief deputy, and investigators from their office respond to the death scene, view the body and do their own research, Chisholm said. They also consult with the medical examiner and with outside experts. They then meet with the victims' families and the families' attorneys.

They used that process to investigate Williams' death and did not find any credible evidence that Williams was abused by police, Chisholm and Lovern said.

All the witnesses they spoke with on the scene - except one - were police officers.

The single non-police witness they interviewed that night was Williams' girlfriend, Sharday Rose, according to Lovern.

Rose's father had been briefly questioned by police and allowed to go home after they determined he was not involved in the robbery attempt, according to Lovern. Rose's father told her Williams was in trouble, so she went to the scene, which was about four blocks away. She told Lovern she saw Williams "going ballistic" and heard him shouting that he couldn't breathe, Lovern said.

Rose told the Journal Sentinel when she begged police to call an ambulance, they threatened to arrest her.

"I ran to the police car and they tackled me down so I couldn't see what was going on," she said.

They then placed her in the back seat of a different squad car, she said.

She said Williams' ankles were shackled as well as his wrists.

Lovern said his notes make no mention of the assertions that Williams' ankles were shackled, that Rose was placed in a squad car or that she asked police to call an ambulance.

Chisholm said his office does not have the staff to seek out witnesses on their own when someone dies in police custody. Rather, he relies on police and on victims' families to bring him the names of other witnesses who might have significant information. In Williams' case, neither of them did, Chisholm said.

The Journal Sentinel made Chisholm aware of a woman who told a reporter she saw police swing at Williams. The woman, who said she did not know Williams or his girlfriend, said she saw the arrest out her back window.

The woman also said she heard Williams telling the officers to stop hitting him. They then dragged him halfway down the block before placing him in the back of Cline's squad car, said the woman, 33.

"He was hitting his head against the window, saying he can't breathe," she said.

The woman asked not to be identified in the newspaper, saying she feared retaliation by police.

She later told the district attorney's office she saw numerous officers hitting, kicking and using Tasers on Williams, which Chisholm said is not consistent with the findings at autopsy or other witness accounts.

Chisholm acknowledged that depending on the police and the public to tell prosecutors about witnesses is not the best system for investigating deaths in police custody.

"Do we do it perfectly? No," he said. "We are always constrained by resources. . . . The ideal thing would be a completely independent agency - the Department of Justice swoops in. But they don't have the resources, either."

The installation of video cameras in squad cars several years ago has made it easier to investigate these types of incidents because it makes his office less dependent on witness statements, Chisholm said.

The decision to use squad cameras was prompted by the death of Mario Mallett in the back of a police wagon in 2001. Like Williams, Mallett carried the sickle cell trait.

Mallett, 29, died after he struggled with officers. His hands were cuffed behind his back and his ankles were shackled when he was placed in the back of the wagon, according to media reports at the time. Contrary to department policy, the only officer in the wagon was the driver, who could not see Mallett in the back.

McCann convened an inquest at the family's request and assigned a special prosecutor from Dane County to the case to avoid potential conflicts of interest. Because some witnesses reported Mallett had been placed facedown in the van, the medical examiner at the time initially suspected Mallett may have died of positional asphyxia - the same condition Williams' family believes may be to blame for Williams' death.

Jeffrey Jensen, the Milwaukee County medical examiner in 2001, eventually ruled out positional asphyxia as the cause of Mallett's death. At the inquest, Jensen testified that Mallett died of a heart attack caused by acute exhaustive mania, a rare and controversial condition sometimes cited to explain deaths in police custody.

Jensen said sickle cell trait, the extreme cold and the fact that Mallett had an enlarged heart contributed to his death.

The inquest jury ruled the death accidental. No charges were filed against any of the officers involved. The city later settled a civil suit with Mallett's family for $200,000.

Chisholm said that although his investigation of Williams' death did not allow for such a public airing of the facts, he has tried to be as transparent as possible with Williams' family - as he does with all the families of those who die in police custody.

That is why Chisholm allowed Williams' mother and aunt and their attorney, Robin Shellow, to watch the squad video that captured Williams' death.

"When you seen the video, it was kind of like a nightmare," said the aunt, Renee Moore. "He was like a fish out of water."

Williams rocked back and forth and gasped as he repeatedly told the officer in the front seat he couldn't breathe and asked for help, according to his family and their attorney. Then his eyes rolled back and he fell sideways, unconscious.

"His last moments on earth were filled with excruciating suffering," Shellow said. "No one should have to go through that much suffering."

Chisholm saw things differently, according to his letter to Flynn.

"The video reveals that Williams appeared to be taking in oxygen, was verbally communicating, and did not exhibit other outward signs of distress, such as seizures or foaming at the mouth," the letter says. " . . . The evidence in this matter makes it clear to me that Mr. Williams' untimely death was caused by a pre-existing medical condition."

Chisholm would not release a copy of the video to the family or to the newspaper. Police Department officials also refused to release the video - or any other records in the case - citing the internal Police Department investigation into possible rule violations.

Shellow believes the video is enough to convince a jury the police ignored a prisoner who needed urgent medical attention.

She has filed a notice of claim, a precursor to a lawsuit, with the city. She plans to seek $4 million in damages on behalf of Williams' three children, ages 3, 2 and 11 months. "We watched a video of a man suffocate to death while officers stood by and did nothing," she said. "It seems to me that's misconduct in public office."