NASHVILLE, Tenn. - The August night was hot, but Charles Jason Toll wrapped himself in a coat and covered his mouth to protect against the electrical shocks and gas he thought might come his way.
Outside the door of his solitary confinement cell at Riverbend Maximum Security Institution here, five corrections officers in riot gear lined up, tensely awaiting the order to go in. When it came, they rushed into the small enclosure, pushing Toll to the floor and pinning him down with an electrified shield while they handcuffed him and shackled his legs.
Toll, 33, a heavyset man who suffered from diabetes and mental illness, said, “I can’t breathe” - a complaint he would repeat, with increasing urgency, at least 12 times that night.
“You’re not going to be able to breathe,” an officer, Capt. James Horton, can be heard telling him on a prison video. And then, “You wanted this.”
The officers carried him, face down, to a dark outdoor recreation yard to search him. A short while later, Toll was dead.
In the insular world of correctional institutions, it is known as cell extraction, the forcible removal of a prisoner from a cell by a tactical team armed with less-lethal weapons like Tasers, pepper spray and stun shields.
Jails and prisons routinely make use of the tactic in response to threatening behavior or disciplinary infractions. Toll, who was in prison on a parole violation and whose death in 2010 the state medical examiner ruled a homicide, had been accused of splashing an “unknown liquid” at a guard through the doorjamb.
While cell extractions are not new, a series of lawsuits and cases around the country are demonstrating the dangers of their widespread use, especially with mentally ill inmates like Toll, who represent an increasing segment of the jailed population and who are disproportionately the targets of force, statistics from several states indicate.
Videos made public in California last fall showed corrections officers at state prisons dousing severely psychotic inmates with large amounts of pepper spray before forcibly removing them from their cells, images that a U.S. district judge, Lawrence K. Karlton, who ordered the release of the videos, termed “horrific.” And in Florida in May, an inmate who was reportedly mentally ill died during a cell extraction at the Charlotte Correctional Institution.
Even when scrupulously conducted, cell extractions carry risks. Officers suit up in Kevlar vests and kneepads to protect themselves from assaults with homemade weapons or other objects. Injuries to inmates - from bruises and lacerations to concussions and broken bones - are common, though no government agency tracks them. In some cases, prisoners have died as a direct result of extractions, like Toll, whose death was caused by “asphyxia and suffocation” from force applied while he was in restraints, the medical examiner found.
Yet despite the frequent use and inherent dangers of cell extractions, states and localities vary widely in when and how they are carried out and in the level of training required of officers who conduct them. Many corrections experts say they believe that extractions are vastly overused.
In some institutions, extraction is viewed as a last resort. Training emphasizes the need to defuse the situation in other ways if possible, and extractions are tightly supervised. Special care is taken when mentally ill inmates are involved.
But in many facilities, training is minimal, supervision is lax and forcible removals are conducted reflexively, with little or no attempt at alternate solutions. Corrections officers who are so inclined can easily turn the process into a vehicle for beatings or other prisoner abuse.
“It can move from a proper tactical exercise to a punitive and retaliatory exercise,” said Steve J. Martin, a lawyer and corrections consultant who has served as a federal monitor and is an expert on the use of force in prisons and jails.
A few months before Toll died, another inmate at Riverbend was kicked, beaten and slammed into a concrete wall while handcuffed and shackled, splitting open his forehead, according to a lawsuit filed in the case. And in Los Angeles in 2008, deputies at the county jail - armed with Tasers, rubber bullets and rubber ball grenades - systematically moved down a tier extracting one inmate after another. Prisoners were choked, beaten unconscious and then shocked back into awareness, court documents show. More than 100 broken bones and other injuries resulted. One inmate required a metal plate in his right eye after multiple fractures to the eye socket; another received Taser shocks to his testicles and buttocks.
Jeffrey Schwartz, a correctional consultant who has worked with a large number of jails and prisons around the country, said that in his view, only about 20 percent of the cell extractions carried out in the United States were necessary.
Inmates, he said, often feel compelled to fight back during an extraction so as to not lose face in front of other prisoners. Officers, too, gear up, like soldiers preparing for battle.
“Once they put on those heavy pads and the adrenaline is flowing, they want to go in,” Schwartz said.
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An Inmate’s Past
Toll was 14 when things began to go wrong.
His stepfather died. He started experimenting with drugs. He was arrested for setting fire to a trash can with a cigarette and then for stealing his father’s car. When he was 18, a series of house burglaries and an escape from a county jail work crew sent Toll to state prison.
Medical records from his years behind bars show his mental and physical health slowly declining. He developed diabetes and high blood pressure. He made suicide attempts.
At various times in prison, he received diagnoses of schizoaffective disorder, bipolar disorder, drug abuse and depression. He carried the scars of self-inflicted injuries, including a deep slash on his right forearm from 2006, after he reported that two other inmates had raped him. A tattoo on each arm depicted a demon’s head - to ward off voices that told him to harm himself, he told people.
Toll had more than 50 disciplinary infractions, many of them minor. But in one instance, in 2009, when he was off his psychiatric medication, Toll was accused of throwing scalding water on an officer, which led to his placement in solitary confinement at Riverbend.
A few weeks before he died, he swallowed 97 Tylenol pills, landing him in the hospital for a few days. When he returned to Riverbend, he got into an acrimonious dispute with a guard who had a reputation for taunting inmates, according to former employees of the prison and depositions taken as part of a lawsuit brought by Jane Luna, Toll’s mother, after his death.
“He was real anxious,” Luna said of her son, recalling a phone conversation she had with him the Sunday before his death.
Shortly after 9 p.m. that Tuesday, Aug. 17, 2010, Horton assembled a cell extraction team to pull Toll out so that it could confiscate any containers he could use to throw liquid.
A prison videotape shows how the cell extraction unfolded. (Most prisons and jails monitor extractions by videotaping them, although prison videographers have been known to point cameras at ceilings and floors when they want to hide what is taking place. In this case, the cameras were trained on Toll, but much was obscured by the bodies of the officers and the darkness of the recreation yard.)
At 9:24 p.m. on the video, Horton can be heard ordering Toll, who had jammed the cell door, to unblock it.
When he did not - “Let’s get it on, goddamn it,” Toll said - the team members, dressed in body armor, black jumpsuits and black helmets, moved in, led by Gaelan Doss, a guard weighing more than 450 pounds and carrying a curved stun shield.
As the officers carried Toll out of the cell - facedown, hands cuffed behind his back - Horton threatened to shock him with a Taser if he did not stop moving. The extraction team took Toll to the farthest cage in the outdoor recreation yard, where they placed him facedown on the ground and began to search him, working in the dark with only a single flashlight.
“Please, please. I can’t breathe,” Toll said.
“Quit resisting, Mr. Toll,” Horton responded.
At 9:33 p.m., Toll began making snoring noises that a medical expert later said indicated that he had slipped into a coma and was near death. The officers continued to search him.
At 9:38 p.m., Marina Tucker, a nurse who accompanied the extraction team, was called to check on Toll. When she found that his lips were blue and he did not respond to his name, she began cardiopulmonary resuscitation.
An ambulance was summoned. At 10:32 p.m., Toll was declared dead.
Protocols and Dangers
Removing a recalcitrant inmate from a cell was once achieved by brute force. Guards in regular uniforms went in and did whatever they needed to subdue a prisoner. But with the rise of super-maximum-security prisons in the 1980s and 1990s, steel and concrete fortresses designed to hold inmates whom politicians called “the worst of the worst,” prison officials codified the procedure to make it safer for officers, using specially trained teams equipped with body armor and less-lethal weapons.
In most jails and prisons, extraction teams are called when an inmate poses an immediate danger - holding a homemade knife or other weapon, for example. Acts of defiance, such as covering the window of a cell, refusing to return a food tray or barricading the door, can also result in an extraction.
Yet despite the addition of formal protocols and protective clothing, the process remains dangerous.
“It’s always violent and it’s always unsafe for staff. It’s unsafe for inmates,” said Brad Hansen, emergency management supervisor for the Corrections Department in Nebraska.
Officers have been stabbed with homemade knives. They have slipped on cell floors slick with water or shampoo. They have been spit on or bitten by prisoners with HIV or hepatitis C, and suffered cuts and bruises from wrestling prisoners to the floor. Schwartz, the corrections consultant, recalled an officer whose leg was badly cut while making a training film on cell extractions.
The highest risk, however, is for prisoners, who wear no body armor and are greatly outnumbered.
Toll, who had been forcibly removed from a cell once before, described to his mother feeling “like a rag doll.” Todd White, the inmate at Riverbend whose head was slammed into the wall by guards after he was already in restraints, said, “You feel helpless. They just come in there and beat the hell out of you and do what they want to do.”
In most jails and prisons, policies on the use of force specify in some detail how an extraction should unfold: An officer, for example, is assigned an inmate’s arm or leg and told to keep that limb under control. But once the team goes in, the reality often bears little resemblance to the paper directives, looking more like a barroom brawl than a tightly orchestrated exercise, said Joseph Garcia, a security consultant.
“It’s chaos,” Garcia said.
His own method, which has been adopted by some jails and prisons, uses only two officers and they do not enter the cell. The officers use weapons like Tasers and 12-gauge shotguns that fire less-lethal ammunition to subdue an inmate, and then restrain him. The method is not free of controversy, but Garcia said that the mother of an inmate might prefer that her son receive a bad bruise on the leg or a Taser shock to having him suffer a broken bone, concussion or worse from a traditional extraction.
As jails and prisons become more populated with mentally ill inmates - in some institutions, 40 percent or more of inmates suffer from mental illness - the situations that provoke extractions have increased. In a system ill-equipped to handle psychiatric symptoms, the behavior of inmates is often treated as a disciplinary problem.
Yet for an inmate who is severely mentally ill, the arrival of a cell extraction team is more likely to instill terror than compliance, mental health experts say.
“It’s demeaning, it’s degrading, it’s frightening,” said Dr. Edward Kaufman, a psychiatrist who has worked extensively in prison settings and served as an expert witness in the California lawsuit. He noted that one psychotic inmate in the California case, shown in a video being pepper sprayed multiple times, had delusions that the guards were trying to rape him. The corrections officers kept ordering him to back up to the cell door and place his hands through the port for the handcuffs, increasing the inmate’s fears.
“The guy keeps screaming, ‘Don’t rape me,’” Kaufman said.
Some states, concerned about injuries and aware that mentally ill inmates are more vulnerable, have begun to provide prison staff members with special training. Officers are encouraged to use what Martin, the corrections consultant, calls “time and distance,” waiting out a situation or negotiating with a prisoner rather than rushing in with a team.
“The use of force, to a certain degree, means you’ve lost,” said Dan J. Pacholke, deputy secretary for operations for the Department of Corrections in Washington, one of several states that have taken steps to try to minimize cell extractions. He added that his department makes extensive use of crisis negotiators and gives staff members special training. Having national standards for how and when cell extractions should be done would help, he said.
Pacholke noted that most extractions take place in solitary confinement units, where inmates are kept under tight control and have extensive idle time, conditions that exacerbate problematic behaviors. To address this, the department has increased activities for maximum-security prisoners and reduced the number of inmates in isolation. At most, 10 to 12 extractions a month are carried out across the state, he said.
Nebraska’s Department of Correctional Services has also taken steps to reduce the use of extractions.
“We got to the point where we thought that there had to be some other way to do it,” said Hansen, the Nebraska official. The number of cell extractions carried out in state prisons dropped to 98 in 2013 from a high of 232 in 2008, he said.
Hansen added that a mental health negotiator is summoned when a disturbed inmate is causing problems, and the department’s policy now dictates that three attempts must be made to talk the prisoner into submitting to restraints before a more aggressive step is taken.
If more severe tactics are required, pepper spray, pumped in from outside the cell, is viewed as preferable to sending in a team of officers, because inmates are more likely to capitulate quickly and no physical combat is involved.
“Cell extractions are the last resort,” Hansen said.
Examining the Events
Ricky J. Bell, the warden at the time of Toll’s death, said in a telephone interview that his officers did nothing wrong that night.
“It’s unfortunate that Mr. Toll died in that extraction,” said Bell, who is now retired. “But I feel the staff did exactly what they should.”
No criminal or disciplinary charges were brought against the officers involved. Last year, a jury in the civil rights lawsuit brought by Luna found that Bell, Horton and Doss were not liable for the death.
“At the end of the day we found 12 jurors who said: ‘He’s an inmate. He’s a criminal. So what?’” said David Weissman, one of the two lawyers who argued the case for Luna.
But former employees of Riverbend who were present that night, as well as three independent corrections consultants and a forensic medical expert who reviewed the videotape of the cell extraction, the autopsy report and other documents at the request of The New York Times, said that Toll should not have died that night and blamed the way the cell extraction was conducted.
“This was such a needless - clearly, objectively needless - death,” said Martin, who has testified in use-of-force cases on behalf of both corrections officials who were defendants and inmates who were plaintiffs.
During the course of the extraction, the officers violated training guidelines, applied force in a dangerous manner, ignored clear signs that Toll was in distress and failed to provide competent emergency care, the former employees and corrections experts said.
Training at the prison was also inadequate, Weissman said. Bell, the warden, discontinued refresher courses in cell extraction at Riverbend for budgetary reasons about three years before Toll’s death, he said in a deposition. Only one officer involved was up-to-date in training, and two had never participated in an extraction before.
A former employee of the prison who was present that night said that the extraction had been mishandled from its start.
“Wrong is wrong,” said the former employee, who spoke on the condition of anonymity for fear of endangering his current job. “It’s wrong in the light and it’s wrong in the dark and that whole deal was wrong.”
He said that the officers placed far too much pressure on Toll’s back and upper body, something that training courses routinely warn increases the risk of suffocation.
“I could see they put their knees against him, against the shield on top of him,” the former employee said, adding that it was hot and that Toll was wearing several layers of clothing, which may have increased his respiratory distress.
Dr. Michael M. Baden, a former chief medical examiner for New York City who reviewed videotape of the extraction, as well as the autopsy report and photographs from the autopsy, said that bruising over Toll’s windpipe appeared to be from “pressure from hands or an arm squeezing on the neck.”
Other marks on Toll’s nose, face and forehead, he said, “are typical for an altercation where force is applied to the face.”
The way the extraction team transported Toll was also problematic, the corrections experts said, running contrary to what is taught in most training courses, which advise against carrying inmates face down by the arms and legs except in an emergency. And although the officers said in legal proceedings that they did not hear Toll say that he could not breathe, the former employee said that all the officers present that night heard the complaints and ignored them.
Perhaps most troubling, the extraction team took Toll to the dark recreation yard instead of a well-lighted multipurpose room or another cell, an option prescribed by training procedures. Prison officials said the decision was made to get him away from the other inmates. But the lights in the yard had been broken for three years, the former employee said, and the darkness made it impossible to monitor Toll’s safety.
“It was a recipe for disaster,” he said.
Even the attempts to provide emergency aid were bungled.
Tucker, the nurse, placed a piece of medical gauze over Toll’s mouth when she began rescue breathing, further obstructing his airway. And compressions were not started until well after rescue breathing began, although the current protocol for CPR advises that compressions should be applied first.
In a telephone interview, Tucker said that her training in CPR predated the current protocol.
She said she had been worried about the way that the officers were carrying Toll. “They kind of had him upside down, and I thought they were putting strain on his arms and legs,” she said.
Neysa Taylor, a spokeswoman for the Tennessee Department of Correction, declined requests to interview department officials or officers about Toll’s death. Horton did not respond to interview requests left with his lawyer and the department. Doss, reached by telephone, refused to comment, and messages left on voice mail and social media for other officers who participated in the extraction were not returned.
After Toll died, internal-affairs investigators at the prison concluded in their report, obtained by The Times, that Toll’s death was “in no way caused by the actions of staff.”
But the investigators, corrections experts who reviewed the report said, failed to interview crucial witnesses, did not ask basic questions in the interviews they did conduct and failed to preserve relevant evidence from the scene.
“It was the most incompetent investigation I’ve ever seen,” said Ron McAndrew, a corrections consultant and former warden at the Florida State Prison, who served as an expert witness for the plaintiff in the Toll case.
At least one officer involved in the cell extraction quit his job in part because of the way the investigation was handled.
In a resignation letter sent to Bell, a copy of which was obtained by The Times, the officer, William Amonette, wrote that he had been treated badly at the prison “ever since I asked questions in your office about the witnesses in the Charles Toll case that were not spoken to by Internal Affairs.”
“I cannot work somewhere where asking questions or trying to do what is right is punished,” he wrote.
The morning after Toll died, the phone rang at Luna’s house at 5:30. A man who identified himself as the prison chaplain told Luna that her son had been found dead in his cell during the night, the cause an apparent heart attack. Nothing was said about the cell extraction.
Since her son’s death, Luna said, she has found it difficult to move on with her life. She has been too depressed to work. The house she shares with a friend is cluttered with boxes, some filled with legal documents, others with mementos from her son.
“I can’t see a future,” she said. “He was my only child. He was my life and I can’t seem to find my next step to go on.”