Report of Investigation
In-Custody Death
Date of Incident: 2/3/2015
Location: Fairfax County Adult Detention Center
Decedent: Natasha J.C. McKenna

Raymond F. Morrogh
Commonwealth's Attorney
Office of the Commonwealth's Attorney
4110 Chain Bridge Road, Room 114
Fairfax, YA 22030

 Purpose
The purpose of this office's investigation was to determine whether any person bears
criminal responsibility in connection with the death of Natasha J.C. McKenna. On February 3,
2015, Ms. McKenna, an inmate in the Fairfax County Adult Detention Center, was involved in a
protracted struggle with Sheriffs deputies who sought to transport her to another facility. The
struggle included physical restraint and use of a Conducted Energy Device (CED). 1 After
deputies had secured Ms. McKenna in a restraint chair and transported her to the sally port, a
nurse, assigned to monitor Ms. McKenna, discovered she was not breathing. Ms. McKenna was
taken by ambulance to Fairfax Hospital. Doctors declared Ms. McKenna brain dead on February
7, 2015. Critical care interventions were terminated the following day and cardiac standstill
ensued.

Background
At autopsy, Ms. Natasha J.C. McKenna (DOB: 1/9/78) was a 5'4, 181 pound, 37 year
old female with a well-documented history of major mental illness. Her first psychiatric
hospitalization occurred when she was 14 years old. In the ensuing years she accrued numerous
psychiatric diagnoses including: schizophrenia, bipolar disorder and depression.4

1 The Conducted

Energy Device (CED) is also referred to as a Taser; Electrical Control Device (ECD); Electronic
control Weapon (ECW) and Conducted Energy Weapon (CEW)
2 Report of Autopsy N072-15
3 Psychological Evaluation, HCA Dominion Hospital (May 2, 1992)
4 Inpatient Record INOVA Mount Vernon Hospital (Generated 3/23/2015 12:52 p.m., p.l)

1

 Recent Relevant Medical and Mental Health Background
On January 7, 2015, Ms. McKenna was transported by ambulance to INOVA Alexandria
Hospital after she reported that her car was rear ended by another vehicle. Alexandria police
reported that there was no damage to Ms. McKenna's rear bumper. She complained of chest,
back and neck pain as well as painful breathing. In addition, Ms. McKenna told hospital staff
that the police were following and harassing her. She also believed that her phone calls were
being monitored. Ms. McKenna was described as agitated and paranoid but denied suicidal or
homicidal ideation. She was released and referred for a voluntary psychiatric evaluation.5
Later that afternoon, Ms. McKenna appeared at the INOVA Springfield HealthPlex
where she complained of chest pain and painful breathing due to the odor of poison gas in her
apartment. She reported that she had been in a car accident and had x-rays taken at INOVA
Alexandria Hospital. Ms. McKenna repeated her claim that the police were following and
harassing her. Staff advised Ms. McKenna to talk to a psychiatric liaison but she refused, stating
"they will just give me psych meds and discharge me anyway." Ms. McKenna left before the
liaison arrived. 6
The next day, January 8, 2015, Fairfax County police officers were dispatched to a fight
in progress. Upon arrival, officers discovered that Ms. McKenna had entered a stranger's car and
refused to get out. The car owner stated that Ms. McKenna refused to exit his car and appeared to
be attempting to strangle herself with the seatbelt. Ms. McKenna refused police commands to
come out of the vehicle. A struggle ensued during which Ms. McKenna was combative and
kicked an officer twice in the chest. The officers were able to remove her from the car and place

5 Inpatient
6 Inpatient

Record INOVA Mount Vernon Hospital (Generated 3/25/2015 pp. 78-92)
Record INOVA Mount Vernon Hospital (Generated 3/25/2015 pp. 55-63)

2

 her in handcuffs. During this incident Ms. McKenna did not respond verbally to officers other
than to make growling noises.
Officers summoned an ambulance for Ms. McKenna as they suspected that she was either
on drugs or suffering from mental illness. The police officers consulted with Woodburn Mental
Health and determined that there was probable cause to believe Ms. McKenna was a danger to
n

herself or others. An Emergency Custody Order was issued for Ms. McKenna. No charges
were filed given Ms. McKenna's apparent mental illness.
Ms. McKenna was admitted to INOVA Mount Vernon Hospital on January 8, 2015.
o

Emergency room staff sedated her intravenously and placed her in restraints. Hospital records
describe Ms. McKenna as agitated, aggressive and combative. She was diagnosed as suffering
from delirium, lactic acidosis, rhabdomyolysis, leukocytosis, delusions, bipolar disorder and
cellulitis of the right leg.9 Ms. McKenna's toxicology screening for narcotics was negative. 10
She was released four days later, on January 12, 2015.
The emergency room physician made the following notes to the file on 1/8/2015:
Labs with significant leukocytosis, lactic acidosis and elevated
CK. Unsure if underlying infection or related to drug use or
physical fighting with multiple police officer. Mobile crisis
responded and will place in TDfor psych admission if necessary.
Will admit for medical clearance given lab abnormalities...11
(emphasis supplied)
On January 14, 2015, Ms. McKenna self- reported to INOVA Springfield HealthPlex.
Medical records indicate Ms. McKenna was nervous, anxious and paranoid. She said that she
was not taking her medication. The records also reflect Ms. McKenna's history of depression,

7 1/8/2015

Report of Officer Pantalena
Record INOVA Mount Vernon Hospital (Generated 3/23/2015 p. 25)
9 Inpatient Record INOVA Mount Vernon Hospital (Generated 3/23/2015 pp. 1-2)
10 Inpatient Record INOVA Mount Vernon Hospital (Generated 3/23/2015 p. 43)
11 Inpatient Record INOVA Mount Vernon Hospital (Generated 3/23/2015 p.8)

8 Inpatient

3

 bi-polar disorder, and psychotic episodes requiring hospitalization. Hospital staff called the
police because they wanted a police officer to obtain a Temporary Custody Order for Ms.
McKenna. 12
Officer Curcio responded to the HealthPlex and spoke with Ms. McKenna. Ms.
McKenna told the officer that she was in a dispute with her landlord because the landlord had
made structural changes to her apartment without her consent. Ms. McKenna repeatedly refused
medical treatment and stated that she wanted to leave. As Ms. McKenna and the officer walked
past the nurse's station, the charge nurse yelled out that Ms. McKenna was "not free to leave!"
The officer asked why not. The treating physician, Dr. Haile, then explained that Ms. McKenna
had "abnormal vital signs." Among these abnormal signs was an elevated heart rate and
respirations. The officer asked if this would be considered life threatening. Dr. Lydia Haile
replied, "It could be. I need to check her out." Based on his observations, as well as the lack of
any suicidal or homicidal statements by Ms. McKenna, the officer explained to hospital staff that
he could not lawfully detain her. The officer gave hospital staff the phone number for the
magistrate's office so that they could try to secure an Emergency Custody Order. 13
Dr. Haile called the magistrate's office in an attempt to obtain an Emergency Custody
Order. However, by this time Ms. McKenna had walked out of the hospital. The magistrate
advised Dr. Haile that he could not issue an Emergency Custody Order if Ms. McKenna's
location was unknown and suggested Dr. Haile call Mobile Crisis. Dr. Haile did so, and Mobile
Crisis suggested she call the police again.
At that point, Dr. Haile had the charge nurse call the police to reiterate her concern that
Ms. McKenna was at risk and needed help. Lieutenant Jocuns informed the nurse that the officer

121/14/2015
13 1/14/2015

INOVAED Record (Generated 3/23/2015 pp. 85-88)
Report of Officer Curcio

4

 followed Ms. McKenna home and spoke with her. He related that the officer believed Ms.
McKenna was safe in her home. The Lieutenant concurred with the patrol officer that there was
insufficient probable cause to obtain an Emergency Custody Order.
Now that Ms. McKenna was located, Dr. Haile, believing that Ms. McKenna was quite
ill, called the magistrate's office again. This time she got a different magistrate on the phone.
Dr. Haile explained to the magistrate that in her medical opinion, Ms. McKenna did not have the
capacity to consent and that it was unclear to her whether Ms. McKenna's altered mental
status was caused by her psychiatric condition and/or a continuation /progression of the
delirium she was diagnosed with while hospitalized at INOVA Mount Vernon Hospital. Dr.
Haile requested the magistrate to issue an Emergency Custody Order for Ms. McKenna. The
magistrate declined to issue the Order and explained that, based upon her conversation with the
Lieutenant, the criteria for an Emergency Custody Order was not met.14
As Dr. Haile explained in her Emergency Department Provider Notes, among her
concerns was that medical Records from INOVA Mount Vemon Hospital on January 8, 2015
indicated that Ms. McKenna "was found to be febrile, confused and was admitted to the medical
unit with several diagnoses of delirium, rhabdomyolysis, cellulitis (given abx) and based on a
prior diagnosis of herpes, was treated with acyclovir.. .On 1/12 she still had leukocytosis and her
CK was 11,000 plus."15
The next day, January 15, 2015, shortly before 7:00 p.m., the manager of a rental car
agency in the City of Alexandria called the police to report that Ms. McKenna was causing a
disturbance at the business. According to the manager Ms. McKenna was acting strangely,
yelling at customers and accusing the staff of trying to kill her. Officer Hurley of the Alexandria
141/14/2015
15 1/14/2015

INOVA ED Record (Generated 3/23/2015 pp. 85-95)
INOVA ED Record (Generated 3/23/2015 p. 93)

5

 Police Department was the first officer on the scene. As she exited her cruiser and began
walking towards the business, Ms. McKenna approached her and began making irrational
statements. Officer Johnson arrived on the scene. Officer Hurley entered the rental agency and
interviewed the manager regarding Ms. McKenna's earlier behavior. Officer Johnson attempted
to keep Ms. McKenna in view as she walked away from the area but lost sight of her. Based
upon her own interactions with Ms. McKenna and the information provided by the manager,
Officer Hurley determined that she had probable cause to take custody of Ms. McKenna for
purposes of a Mental Health Evaluation.
A short while later Officer Hurley located Ms. McKenna as she walked near a Home
Depot store. Officer Hurley stopped Ms. McKenna who stated that "they were trying to kill
her." Officer Hurley explained that she was concerned about Ms. McKenna's welfare. By this
time Officer Johnson was also present. Ms. McKenna asked if she was going to be arrested and
began to walk away. Officer Hurley took Ms. McKenna's left arm and told her she was not free
to leave. Officer Johnson had hold of Ms. McKenna's right arm. Ms. McKenna began to fight
with the officers. Officer Johnson attempted an arm bar on Ms. McKenna and employed closed
fist strikes to the back of Ms. McKenna's thigh in an effort to have Ms. McKenna sit down.
Despite Officer Hurley's request that she stop resisting, Ms. McKenna continued to fight.
Officer Johnson deployed OC (pepper spray) but it had no effect on Ms. McKenna. Ms.
McKenna then punched Officer Johnson in the face and spun away coming out of her shirt in the
process. She then ran out into traffic while naked from the waist up.16
Officers pursuing in their cruisers followed her to the back of the Home Depot. By this
time two additional officers arrived and assisted in trying to control Ms. McKenna. When
Officer Gordon arrived she saw officers trying to hold Ms. McKenna down on the ground.
16 Narrative

of Officer Hurley (Generated 2/18/2015, pp. 1-3)

6

 Officer Gordon heard Officer Powers asking Ms. McKenna to stop resisting. Ms. McKenna was
attempting to pull her hands out of her handcuffs. Officer Powers had a hold of Ms. McKenna's
ankles and Officer Gordon placed a hobble around them. Officer Gernatt arrived and assisted in
trying to control Ms. McKenna. Due to Ms. McKenna's continuing struggle to escape from the
handcuffs, Officer Gordon put a second set of handcuffs on Ms. McKenna above the first set.
Officer Riley also assisted in trying to subdue Ms. McKenna.
Ms. McKenna continued kicking and violently struggling to break free of the restraints.
In order to avoid the possibility of positional asphyxiation, as well as to get Ms. McKenna's
exposed body off of the cold ground, the officers moved Ms. McKenna to a seated position
against a fence. The officers then retrieved a blanket and covered Ms. McKenna. While Officers
Leach and Johnson attempted to stop Ms. McKenna from struggling against the handcuffs she
resumed kicking her legs. Then, using her toes for leverage, Ms. McKenna slumped down and
pushed herself away from the fence and scooted across the ground causing her pants to come
down past her thighs. Officer Stowe replaced the blanket over Ms. McKenna but the officers
were unable to stop her from moving and inching across the ground. Officer Stowe observed
Officer Gordon struggling to prevent Ms. McKenna from banging her head on the ground. He
then joined in the efforts to control Ms. McKenna. The officers could hold the blanket on her for
approximately a minute before she would push herself further along the ground and out from
under the blanket. During this portion of the struggle Ms. McKenna kept attempting to bite the
blanket.. The officers told Ms. McKenna that a medic was on the way to wash the pepper spray
off but she remained uncooperative.17

17 Supplemental

Narrative Officer Gordon (Generated 2/18/2015 p. 7)

7

 The officers decided to carry Ms. McKenna to a cruiser to wait for the ambulance. As the
officers carried Ms. McKenna she attempted to bite Officer Bing.18 She also made a sound
consistent with the gathering of saliva in her mouth. The officers placed a spit sock over Ms.
McKenna's head to prevent her from biting and spitting.19 Ms. McKenna began chewing on the
spit sock and attempted to kick the officers. At that point, given Ms. McKenna's level of
resistance, the officers determined that they could not get her safely into the cruiser. Since they
could now hear the ambulance coming, the officers set Ms. McKenna down on the ground with
the blanket over her. Officer Gordon then spoke to Ms. McKenna in a quiet voice. She told Ms.
McKenna that they were trying to help her and that she needed to stop struggling so she would
not hurt herself. Ms. McKenna began screaming that the police were raping her. She continued
to struggle and would not stay still.
When the ambulance arrived the officers explained to the medics the difficulties they had
in controlling Ms. McKenna. The officers worked with the medics to come up with a solution as
to how to transport Ms. McKenna safely to the hospital. One of the medics called the hospital
90

and obtained permission to inject Ms. McKenna with a sedative to calm her down.

•

The medic

advised that it would take a while for the medicine to take effect.
The officers lifted Ms. McKenna on to a stretcher and Officer Gordon tied the strap from
the hobble around the stretcher. Medics placed a sheet over Ms. McKenna and strapped her
down. Officer Young volunteered to ride in the ambulance to protect the medics and Ms.
McKenna was transported. Officer Gordon followed the ambulance to the hospital. When they
arrived at the emergency room Ms. McKenna was still trying to bite through the spit sock. She

18 Supplemental

Narrative Officer Gordon (Generated 2/18/2015 p. 8)
Narrative Officer Stowe (Generated 2/18/2015 p. 18)
20 Supplemental Narrative Officer Riley (Generated 2/18/2015 p. 16)
19 Supplemental

8

 pushed her entire upper torso off of the stretcher and to the side. She continued to struggle and
push herself off of the stretcher by wriggling under the straps.
Medics and officers pushed the stretcher to a room and positioned it next to a bed.
During the transport Ms. McKenna struggled and repeatedly grabbed hold of Officer Riley's
fingers. The Officers then met with hospital staff to discuss the best way to get Ms. McKenna
into the hospital bed. An emergency room technician cut Ms. McKenna's pants off from around
her ankles. He then put hard restraints on Ms. McKenna's ankles. The Officers and technicians
then lifted Ms. McKenna using the hobble and hard restraints to keep her from kicking. They
repeated the process with her arms and the technician attached the restraints to the bed frame.
Officer Gordon, with the assistance of Officer Riley, was able to get both sets of
handcuffs off of Ms. McKenna. However, fearing that the hospital restraints might not be
enough to hold Ms. McKenna, the nurse asked the officers to put the handcuffs back on her. The
Officers then handcuffed Ms. McKenna to the bed frame on each side. Throughout this process
Ms. McKenna continued to struggle, scream and whip her head around.
Dr. Herrington came in and attempted to speak to Ms. McKenna regarding her condition.
Ms. McKenna continued screaming and trying to yank her hands out of the restraints. She would
sit up suddenly and struggle against the restraints. Each time the nurse came in to provide
medical assistance Officers Gordon and Young had to hold Ms. McKenna's arms down to
prevent her from hurting herself or the nurse. At one point, after Ms. McKenna continued
screaming and resisting a nurse's efforts to take a urine sample, it took four officers, Hurley,
Johnson, Young and Gordon to hold her down despite the restraints and handcuffs. Ms.
McKenna repeatedly shook off the blanket covering her body.

9

 Later, nurses came in to take a chest x-ray and Ms. McKenna attempted to turn the bed
over by rocking it back and forth from rail to rail. She was able to move the bed several feet
before officers could secure the brake on the bed. They again held her down while a nurse took a
blood sample and put an IV into Ms. McKenna's arm. The nurse subsequently wrapped up the
IV to prevent Ms. McKenna from pulling it out. Alexandria Hospital records describe Ms.
McKenna's behavior as " forcefully fighting against all people in the room; very strong use of all
extremities; attempting to bite people who are near; says she will be killed; actually answers
some questions while fighting; persistent, deliberate attempts to get untied x 15 min until given
IM Haldol."21
From time to time Ms. McKenna would alternate between quietly lying in the bed to
sitting up and moaning. At approximately 11:30 p.m., Officer Gordon, observing this behavior,
asked Ms. McKenna if she was okay. When Ms. McKenna responded by saying she was more
comfortable sitting up, Officer Gordon removed the handcuffs and with the assistance of a nurse
adjusted the restraints to make Ms. McKenna more comfortable. Ms. McKenna allowed them to
cover her body with a gown. Eventually Ms. McKenna fell asleep.22
Shortly before midnight, Dr. Herrington advised Officer Gordon that she had successfully
obtained an Emergency Custody Order from the Magistrate. Dr. Herrington further advised that
in light of some of the lab results, they were concerned about a medical issue in addition to the
psychosis Ms. McKenna was experiencing.23

21 Consults

by Always, David W, MD at 01/16/15, Alexandria Hospital (Generated on 3/25/2015 p. 173)
Narrative of Officer Gordon (Generated February 18, 2015 pp. 6-11)
23 Supplemental Narrative of Officer Gordon (Generated February 18, 2015 pp. 11)

22 Supplemental

10

 Ms. McKenna's Hospitalization 1/15/2015-1/25/2015
Ms. McKenna was admitted to INOVA Alexandria Hospital on January 15, 2015,
following the above described lengthy combative interaction with police and hospital staff. On
the medical unit, Ms. McKenna was diagnosed with altered mental status, rhabdomyolysis,
leukocytosis and acute renal failure. In addition she suffered from schizophrenia, depressed bi­
polar disorder and herpes simplex.24 Ms. McKenna's lab work also reflected results "remarkable
for elevated creatine kinase [CK] and WBC [white blood cell count] on admission."25
On January, 17, 2015 an Alexandria police officer picked up the Emergency Custody
Order and served it on Ms. McKenna. He then transported her from INOVA Alexandria Hospital
to the psychiatric unit at Mount Vernon Hospital.26
On January 18, 2015, Dr. Radha Agepati authored a psychiatric admission note which
included a reference to Ms. McKenna's status. He included a section titled Past Medical History.
Under that section he wrote that Ms. McKenna's past medical history was "[significant for
status post rhabdomyolysis, leukocytosis, which is resolving and acute kidney injury which is
also resolving and patient has abrasions and swollen hands, which is also coming down
significantly. History of herpes simplex in the past."
On January 20, 2015, a nurse noted that Ms. McKenna's minor friction wounds on her
wrists which she incurred while in restraints at the hospital were aggravated. Ms. McKenna
admitted to scrubbing her wounds with a toothbrush. According to the nurse this probably caused
further superficial damage. Healing ointment was prescribed.

24 Inpatient

27

Record INOVA Mount Vernon Hospital (Generated 3/23/2015 pp. 169-170)
Record INOVA Mount Vernon Hospital (Generated 3/23/2015 pp. 170-171)
26 Supplemental Narrative of Officer Mikhin (Generated February 18, 2015 p.11)
27 Inpatient Record INOVA Mount Vernon Hospital (Generated 3/23/2015 p. 189)
25 Inpatient

11

 On the morning of January 21, 2015, Ms. McKenna was "extremely paranoid." She
became uncooperative and began fighting with staff. She kicked, bit, scratched and spat upon
male staff members. She also urinated on the bed declaring "I have herpes and I don't want
you'll to get it, but I'm not afraid to give it to you." A "Code Strong" was called. Nurses
summoned hospital security. Security staff arrived and strapped Ms. McKenna to a "transfer
board" and placed her in a "quiet room."28
Later in the afternoon, Ms. McKenna informed medical staff that her finger was slammed
in a door. Ms. McKenna stated "it wasn't an accident too!" She was reluctant to let medical staff
examine her finger. Dr. Sadia Hamid examined her after she declared she "wanted a piece of her
finger sutured back on." Dr. Hamid noted a "crush type injury to the distal phalanx of L[ef]t
index finger." Dr. Hamid also noted dried blood on Ms. McKenna's hands.29 Ms. McKenna
subsequently admitted that she caught her finger in the door.30
Mount Vernon Hospital discharged Ms. McKenna on January 25, 2015 at 12:30 p.m.
Staff called for a taxi, gave Ms. McKenna a cab voucher, and escorted her to the taxicab.31 Later
that evening, at approximately, 10:00 p.m., Ms. McKenna arrived by ambulance at INOVA
Fairfax Hospital after she reported a sexual assault. According to Ms. McKenna, she had been
attacked by an Hispanic male who stmck her in the head and eye causing her to lose
consciousness.32 She complained of pain to the left side of her head as well as rectal and vaginal
pain. She refused a physical exam and a CAT scan. Ms. McKenna first requested a SANE exam

28 Progress

Notes by Ross, Cardina RN at 01/21/15, Mount Vernon Hospital (Generated 3/23/2015 p. 192)
Notes by Hamid, Sadia, MD at 01/21/15, Mount Vernon Hospital (Generated 3/23/2015 p. 193)
30 Progress Notes by Waitt, Rebecca C, RN at 01/23/15, Mount Vernon Hospital (Generated 3/23/2015 p.212)
31 Progress Notes by Odeyale, Rasidat, RN at 01/25/15, Mount Vernon Hospital (Generated 3/23/2015 p.215)
32 1/25/15 Report of Officer Duffy

29 Progress

12

 but then refused it.33 Police reviewed the security video from the commercial establishment
where Ms. McKenna claimed to have been accosted. The video did not support her claims.34

Incarceration at the Fairfax County Adult Detention Center 1/26/2015 - 2/3/2015
Fairfax Hospital cleared Ms. McKenna for release and officers arrested her on an
outstanding warrant from Alexandria City charging felonious assault on an Alexandria police
officer arising from the January 15, 2015, incident.

oc

This warrant was issued by an Alexandria

magistrate on January 20, 2015. Fairfax County police brought Ms. McKenna to the Fairfax
County Adult Detention Center where she was taken before a magistrate and held on no bond.
She was transferred to the custody of sheriffs deputies.36
On January 27, 2015 Ms. McKenna covered her cell window with wet toilet paper. She
also blocked her food slot with a blanket and sheet. She refused deputies' requests to remove the
items. Eventually, the deputies pulled the blanket and sheet out of the food slot. Deputies
requested forensic staff to check on Ms. McKenna. At first Ms. McKenna claimed the deputies
had injured her finger while pulling the sheet from her food slot. She later admitted that it was an
older injury that had reopened. She refused medical treatment. Dr. Martin decided to place Ms.
McKenna on RI ["Restricted Issue"] and she was issued a suicide prevention smock and a
suicide prevention blanket.37
On the morning of January 31, 2015, Deputies Thompson, Hedrick and Viola went to Ms.
McKenna's cell to remove a mattress that she had used to cover her window. One deputy opened
the cell door while the other two attempted to pull the mattress out into the hall. Ms. McKenna
33 Field

Notes of Detective Flanagan dated 04-03-15 p. 156
Report of Officer Griffin
35 Va. Code § 19.2-72 requires police officers to execute outstanding warrants.
36 1/25/15 Report of Officer Duffy
37 FCSO Incident Report of Pfc. Xu 1/27/15 pp. 1-2
34 1/25/15

13

 grabbed hold of the mattress and held on firmly. As Ms. McKenna's body broke the plane of the
door, deputies tried to force her back into the cell by pushing her. Ms. McKenna "resisted
immediately with all her force. Her body went to the ground with her lying on her back outside
of her cell where she violently attempted to bite, claw and kick us [the deputies] in an enraged
out of control state of mind."38 According to Deputy Hedrick, "I could not keep her from biting
by pushing on her head so I applied an open hand strike to her forehead area; it did not stop her
attempts to bite us." Ms. McKenna scratched Deputy Hedrick in the face and on the forearms as
he was trying to restrain her from biting." The three deputies were unable to get Ms. McKenna
back into her cell and called for help over the radio. Numerous other deputies arrived, including
Holmes, Guevarez, Timothy, Shifflett, Delaney and Steinbach. When Guevarez arrived he
observed Deputies Viola, Thompson and Hedrick on top of Ms. McKenna. She was fighting
vigorously trying to kick and punch.39 A protracted struggle ensued before deputies were able
to move her to a chair. Deputy Guevarez stated, "I can honestly say that she is one of the
strongest females I have ever encountered in my 11 Vi years."40 Deputies put the rip hobble on
her knees and used a towel to control her head. They handcuffed Ms. McKenna behind her back.
When they finally got her in the restraint chair they placed a spit mask on her because she was
trying to spit. She then urinated on herself. 41 Nurse Kassaye, came in and checked the straps.
She told the deputies to loosen them and they did. Deputy Guevarez wheeled the restraint chair
from Post 27 to Post 4. By the time they arrived there, she had almost succeeded in getting her
hand out of the restraint. They retightened the restraint.

38 FCSO

Incident Report of Deputy Hedrick 1/31/2015 p.l
2/18/2015 Guevarez, pp.6-7
40 Tr. 2/18/2015 Guevarez, p. 7
41 Id. p. 8

39 Tr.

42

ta

„ n

14

AD

Deputies continued to have issues

 with the restraints and could not fix them. Deputy Reeves saw Ms. McKenna attempting to gnaw
through the shoulder restraints. 43
At that point SERT was activated. Sergeant Timothy was the SERT leader. Additional
SERT members present were Deputies Meeks, Shifflett, Barb, Kim and Reeves. Deputy Kim
looked in the cell window and observed that Ms. McKenna had worked her arm free of the
restraint and was waving it. 44 Deputy Kim entered the cell for the purpose of re-securing her
arm. He encountered great resistance from Ms. McKenna. In describing his attempt to secure
Ms. McKenna's arm Deputy Kim stated, "...It might sound easy but... when you are trying not
to hurt that person it gets hard." 45 Ms. McKenna was able to work her arm loose a second time
and SERT members decided to move her to a new chair. They wheeled her to a bigger cell
where they would have more room to deal with her. It took five deputies forty minutes to
transfer Ms. McKenna to the second chair because she fought them. She would thrust her hips up
to prevent being strapped and she was spitting and biting at deputies.46 At one point Ms.
McKenna suddenly appeared to "nod off' or "pass out" very briefly. Her eyes closed and she
dropped for a second. She then recovered and seemed to be unaware of what had happened.
Deputies were unsure of whether she was faking this or not. 47 She remained in the chair for
several hours. She was offered food and water. Nurses and deputies checked her regularly.
Later she was removed from the chair and medically cleared 48
The deputies involved in this January 31, 2015, incident attested to Ms. McKenna's
extraordinary strength and endurance. Unusual strength is a characteristic of excited delirium

43 Tr.

2/19/2015 Reeves, p. 7
2/18/2015 Kim, p. 5
45 Tr. 2/18/2015 Kim, pp. 6
46 7/7/2015 Report of Detective Griffith p.69
47 ID. p.69; Tr. 2/18/2015 Timothy, p. 30
48 FCSO Incident Report of Deputy Lynn Hedrick dated 1/31/2015 pp. 1-2
44 Tr.

15

 syndrome. 49 Sergeant Timothy said, "For me it's probably the most difficult inmate I've ever
had to deal with in that capacity, male or female... And I've dealt with... men on PCP
fighting... it's like she didn't feel pain..." 50 Deputy Guevarez said, "...1 remember it was ... a
struggle. I mean...I'm not a weak guy but she, she was wearing me out; she was wearing us all
out."51 Deputy Holmes said, "...in my 19 years, that was the worst inmate.. .1 have ever dealt
with. I'll be honest with you... she was the real deal. Seriously, she was the worst... the hardest
inmate.. .I've dealt with big guys, I've dealt with other females, smaller guys, guys in gang[s].
She was the toughest person that... I have ever dealt with to get her in that chair and with a
struggle." 52 Deputy Viola said, "[Ms. McKenna was] probably one of the most aggressive
CO

inmates I've ever had to deal with ...in my experience."

Deputy Barb recalled that, "...She

was pushing with the most force I've seen in the... six years I've worked there.. .1 had never
seen anybody push like this..."54
Deputy Shifflett said, " [I]t lasted so long that... all my latex gloves split...which
concerned me after I later learned she had MERSA (sic) and other things.. .1 hate to describe it
like this, like a demonic possession because she was growling the whole time...She would growl
and bite if someone didn't hold.. .her head... to keep her from biting...[the] spit net was doing
no good, she was chewing holes and biting through the spit net.. .She's strong I mean actively
resisting. It. was a good forty to forty-five minutes to take her out of one chair and put her in
another chair.. .my SERT uniform I got soaking wet with sweat again just from the active

49 White Paper Report on Excited Delirium Syndrome, ACEP Excited Delirium Task Force, American College of
Emergency Physicians, September 10, 2009 p. 7-8 ("superhuman strength")
50 Tr. 2/18/2015 Timothy, p. 12
51 Tr. 2/18/2015 Guevarez, p. 8
52 Tr. 2/18/2015 Holmes, p. 7
53 Tr. 2/13/2015 Viola, p. 4
54 Tr. 2/18/2015 Barb, p. 5

16

 resisting." 55 Deputy Reeves said that Ms. McKenna was, "[v]ery difficult.. .she continued to
fight.. .her strength was amazing.. .1 had never encountered anybody like that who wasn't on
PCP before.. .just a surprising amount of strength for her size and build and just constantly
fighting; she never seemed to tire."56
On February 3, 2015, Mr. Tueimer of the Alexandria Community Services Board called
Ms. Bartlett LCP, CSAC, QMACM of the Fairfax Falls Church Community Services Board to
say that the Alexandria Adult Detention Center had alerted him that Ms. McKenna was possibly
in need of mental health intervention. Ms. Bartlett advised Mr. Tueimer that Ms. McKenna was
"currently psychotic, aggressive and easily agitated and she was exhibiting biohazard type
behaviors like smearing feces and drinking her urine." Mr. Tueimer agreed that once Ms.
McKenna arrived at the Alexandria Adult Detention Center she would likely be hospitalized.57

The SERT team
SERT stands for Sherriff's Emergency Response Team (hereinafter SERT). Its members
are highly trained in tactical response for high risk or emergency situations. SERT is a support
unit whose function is to safely, quickly and effectively assist agency operations in the
maintenance or restoration of order.

co

SERT membership is competitive and applicants are

screened by a selection panel consisting of the SERT Commander and at least two SERT
members. Applicants must also be full time deputy sheriffs with at least two years of
correctional, law enforcement or military experience. One year of the requisite experience must
have been attained in the Fairfax County Adult Detention Center. In addition, the candidates

55 Tr.

2/18/2015 Shifflett, pp. 5-6, 8, 13
2/19/2015 Reeves, p. 5
57 Progress Note by Ms. Bartlett, Fairfax Falls Church CSB
58 Fairfax County Sheriffs Office, SOP Number:522 p.l
56 Tr.

17

 must hold the rank of Master Deputy Sherif or below; possess a class "A" physical exam status;
have no formal disciplinary action within the last two years and have no record of excessive use
of force.59
Except in cases of sudden emergency, the use of a SERT response requires approval by a
Deputy Sheriff Captain or above. The SERT may be utilized for events including: riots;
disorders and disturbances; high risk transportation; cell extractions and suicidal inmates.60
Training for all SERT members is ongoing and occurs on a monthly basis.61

Sheriff's Office Standard Operating Procedures Regarding Use of Force
The purpose of the Sheriffs Use of Force Procedures is to provide guidelines for deputies
in the use of force.

f\0

The policies of the Sheriffs Office permit force to be used only when

reasonably necessary to defend oneself or another. Force may also be used to control a person
during a detention. Reasonable force is defined as the use of any force, deadly or not, that is
reasonable in the light of the facts and circumstances confronting the deputy without regard to
the deputy's underlying intent or motivation. Deadly force is described as any level of force that
is likely to cause death or serious injury to a human or animal. Non-deadly force is force which
is not intended to cause death or serious bodily injury. The use of any instrument or technique to
employ non -deadly force may constitute deadly force pending upon the totality of the
circumstances. Less lethal force is defined as force created by kinetic energy impact projectiles,
which may cause death or serious injury but when used properly, significantly reduce the

59 Fairfax

County Sheriffs Office, SOP Number: 522 p. 2-3
County Sheriffs Office, SOP Number: 522 p. 3-5
61 SERT Training Rosters from January 2014 through December 2014
62 Fairfax County Sheriffs Office, SOP Number: 032 p.l
60 Fairfax

18

 probability of such outcomes. Excessive force is force which is determined to be not reasonably
necessary. 63
The Sheriffs Office use of force procedures recognize that individuals may present as
cooperative, resistant or as assailants. A low risk assailant is a subject who presents a risk of
only minor injury. A high risk assailant is one whose actions will probably cause serious
physical injury, with or without a weapon. Deputies have up to five levels of control in dealing
with assailants. First is social control, identification of authority or show of force. Next is verbal
control or issuing orders which require obedience to the rules of the institution. Then weaponless
physical control is recommended, for example, holds and low pressure striking. After that are
control options with weapons. This refers to the deployment of ECD's, OC and Chemical agents
or implementation of tactical cell entry team which is what occurred in the instant case. The
final option is deadly force which is defined as any type of force in which the deputy could
reasonably predict an outcome of death or serious bodily injury. 64
The procedures governing non-deadly use of force require, "when possible, only that
level of non-deadly force reasonably necessary (e.g., physical control techniques, striking with a
baton or other instrument, discharging OC, an ECD, Pepper Ball System or... etc.) to establish
control and gain compliance shall be used in response to opposing force." Enforcing
compliance (with orders, laws, institution rules, and regulations) is considered to be a situation
where non-deadly force may be effectively used. 65

63 Fairfax

County Sheriffs Office, SOP Number: 032 p.l
County Sheriff's Office, SOP Number: 032 p.2
65 Fairfax County Sheriff's Office, SOP Number: 032 p.2
64 Fairfax

19

 Sheriff's Office Standard Operating Procedure Regarding Use of ECD
ECD is an acronym used by the Fairfax County Sherriff's Department to refer to an
Electronic Control Device.66 The Medical Examiner, in her report, refers to the same device as a
CED or Conducted Energy Device. 67 The United States Department of Justice (USDOJ) and
the Police Executive Research Forum (PERF) in a joint publication, 2011 Electronic Weapon
Guidelines, use the term ECW or Electronic Control Weapon. Others, including some deputies,
use the brand name of "Taser" when referencing the device. Fairfax County police use the term
CEW which stands for Conducted Energy Weapon. In each instance, all references are to the
same apparatus; the Taser Model X26.
The Fairfax County Sherriff s Office has a policy of utilizing non-lethal control devices
when practical. The use of an ECD is recommended when appropriate to use and where it might
reduce the risk of injury or death to those involved.68 Authorized users of ECD's include only
those deputies who have completed the user or instmctor training course, and are currently
certified. Trained SERT members on assignment are also authorized to use the ECD.69 Deputies
are authorized to use the ECD to control a violent or potentially violent subject when the deputy
reasonably believes that deadly force does not appear to be reasonably necessary, and attempts to
gain compliance of the subject by verbal commands or physical control have been, or will likely
be, ineffective in the situation. 70 The deputy must consider the potential injury to suspects who
are running, travelling at high speeds (bikes, mopeds, skateboards etc.) or situated in elevated
places. Age and known physical handicaps should also be taken into consideration. 71 Each

6

Fairfax County Sheriffs Office, SOP Number: 525 p.l
Report of Autopsy N072-15 p.4
68 Fairfax County Sheriffs Office, SOP Number: 525 p.l
69 Id. p. 2
67

20

 discharge of an ECD is investigated and documented and a report prepared.

79

It is recommended

that when deploying the X26 ECD, deputies deliver the full 5 seconds of electrical current as
programmed into the device in order to gain maximum effectiveness.

Whenever possible, a

verbal warning that force will be used if compliance is not obtained. 74 The use of the ECD must
be reasonable based upon the totality of circumstances known to the deputy. 75 The policy on
deployment of the ECD recognizes that there are times where after the initial impact of the
probes that a follow up charge will have to be deployed in order to gain compliance and safely
control the subject. The policy warns deputies not to remove the probes until the subject is in full
restraints.

Medical attention must be given to any subject who has been stunned as soon as

possible and when safe to do so.77 Deputies must perform a spark test upon receipt of the ECD
to ensure that it is in proper working order. 78

Activation of the SERT
On Tuesday February 3, 2015, squad supervisor, Lt. Charles Taggart, aware that Ms.
McKenna had injured a deputy during a violent encounter over the weekend and that she was
creating a bio hazard that morning by throwing urine under her door and into the hallway,
informed Lt. Lucas Salzman that they were going to transport Ms. McKenna to Alexandria. He
told Lt. Salzman that deputies had to use force to control Ms. McKenna over the weekend.
Lt. Perkins activated the SERT team based upon several factors; Ms. McKenna had
created a bio-hazard; she was noncompliant with deputies; she had to be placed in a restraint

72 Id.

p. 2
p. 3
74 Id. p. 3
75 Id. p. 3
76 Fairfax County Sheriffs Office, SOP Number: 525 p. 3
77 Id. p. 3
78 Fairfax County Sheriffs Office, SOP Number: 525 p. 4
73 Id.

21

 chair; she fought violently with deputies a few days before. Between 9:00 a.m. and 9:15 a.m. Lt.
Salzman, a SERT member since 2006, alerted Lt. Paul Miller that SERT would be activated
between 10:00 and 10:30 to remove Ms. McKenna to Alexandria. 79 SERT member, Deputy
Adam Henry, received a message from fellow SERT member Deputy Jonathan Perryman
alerting him that a cell extraction was planned for Ms. McKenna. Deputy Perryman also alerted
SERT members Deputy Patrick McPartlin and Deputy Kenneth Krstulovic of the extraction.

Lt. Salzman visits Ms. McKenna's cell
Upon learning that he was to lead a cell extraction team for Ms. McKenna, Lt. Salzman
went to her cell to assess the situation. He noted that there was urine in the hallway outside her
cell with a blanket positioned on the floor to prevent the urine from spreading. He approached
the window of the cell and spoke face to face with Ms. McKenna. He told her that they were
going to bring her to Alexandria. She replied that her boyfriend told her not to leave the jail. In
Lt. Salzman's experience and based upon Ms. McKenna's irritated demeanor and statements, he
did not believe she would voluntarily comply with the transportation process. However, he was
cognizant of the fact that she would have another opportunity to cooperate with deputies before
the cell extraction began.80

19 Tr.
80 Tr.

2/6/2015 Salzman, p.2
2/6/2015 Salzman, pp. 16-20

22

 The Briefing
Lt. Salzman held a meeting with the SERT team at approximately 10:30 a.m.to prepare
for the potential extraction. Using a dry erase board and in conformance with his training at the
Fairfax Criminal Justice Academy, he explained extraction assignments for each member of the
team. Ideally, the SERT training calls for a five man stack with each member assigned particular
duties as well as an identifying number.81 Lt. Salzman assigned Deputy Perryman as number
one (1) meaning he would carry the shield and be first in line. His job was to go in first, protect
the rest of the team and pin the prisoner in place. Deputy Henry was number two (2) and second
in line. His task was to restrain Ms. McKenna's hands. Deputy McPartlin was three (3) and
Deputy Krstulovic was four (4). They were tasked with controlling Ms. McKenna's legs and
feet. Lt. Salzman designated himself as number five (5). His role was to be fifth and carry the
Taser in case it became necessary to deploy it.

89

Lt. Salzman is experienced in the use of Taser

having first completed certification in 2006. Since then he has re-qualified every year and is
currently an instructor in the use of the ECD or Taser. 83
Lt. Salzman briefed the team on Ms. McKenna's mental illness, combativeness, history
of assault on law enforcement officers and Adult Detention Center deputies as well as recent
biohazards including fecal matter in her cell and possibly in her hair and the fact that she had
thrown urine under her cell door.84 The SERT team donned stab proof vests, gloves, extraction
helmets and white Tyvek suits. They also wore gas masks as Ms. McKenna was a known
spitter.85

81 Lesson Plan Cover Sheet and Supplemental Pages (Revised January 8, 2009) Fairfax Criminal Justice Academy
*[pages not numbered]
82 Tr. 2/6/2015 Salzman, pp. 21-23
'
83 Tr. 2/11/2015 Salzman, p. 2
84 3/16/2015 Report of Detective Farrell; Tr. 2/6/2015 Salzman, p. 25
85 3/16/2015 Report of Detective Farrell

23

 Lt. Salzman asked Lt. Miller to act as the door operator. The door operator has the
responsibility to attempt to gain voluntary compliance from the prisoner if possible and thus
avoid a forcible extraction. Lt. Miller wore his regular garb including a black sheriffs shirt and
black slacks. He did not wear a mask or other covering. His duties included locating the inmate
within the cell, verifying that she was not armed, giving commands to the prisoner and verifying
whether she was complying with the commands. Lt. Taggart, who was not a SERT team
member, was tasked with operating a camera and filming the events.

The Video and the timing of certain events
Lt. Taggart captured the incident on Camcorder. Due to the narrow hallway and the
number of personnel participating, parts of the ensuing struggle are obscured by the bodies of
SERT members. Where appropriate below, the writer will make reference to the elapsed time on
the video in reporting the events in question.
SERT came into physical contact with Ms. McKenna for the first time at the two minute
four second (2:04 video) mark on the video. Deputies were able to secure her into the restraint
chair approximately twenty-one minutes and five seconds (21:05 video) into the video. Ms.
McKenna struggled with deputies for a period of approximately nineteen minutes and one
second before deputies were able to sit her back in the restraint chair to the point where she could
be transported safely.
It appears from the video that CEW was used drive stun mode at approximately
seventeen minutes and twenty seconds (17:20 video), probe mode at approximately eighteen
minutes and one second (18:01 video), drive stun and probe mode at approximately nineteen
minutes fifteen seconds (19:15 video), and drive stun and probe mode at approximately twenty

24

 minutes (20:00 video). A period of approximately two minutes and thirty seven seconds elapsed
from the first use of the CEW to the last. Ms. McKenna is still actively moving her legs at
twenty three minutes and thirty seconds (23:30 video). She is still conscious and moving her
legs three minutes and thirty seconds after the last deployment of the CEW.86
Nurses began evaluating Ms. McKenna at approximately twenty three minutes and seven
seconds (23:07 video). Nurse Lamin resumed her evaluation of Ms. McKenna in the sally port at
approximately thirty one minutes and twenty five seconds (31:25 video). Lt. Miller requested
rescue at thirty four minutes and forty one seconds (34:41 video) (duration of approximately
eleven minutes and thirty four seconds from the first medical staff evaluation to the call for
rescue). The transport from the hallway outside cell FR-2 to the sally port took staff three
minutes and fifty one seconds. Rescue arrives on scene at approximately forty one minutes and
five seconds (duration of approximately six minutes and twenty four seconds from Lieutenant
Miller's request for rescue).

86

Di Maio, Vincent J.M., Excited Delirium Syndrome Cause of Death and Prevention (CRC Press, 2006) at. p. 42
(" If death is due to ventricular fibrillation or asystole produced by the TASER pulse, then the individual would lose
consciousness immediately ( 3 to 4 seconds up to a maximum of 10 to 15 seconds)"); see also Bozeman, William P.
et al.' "Safety and Injury Profile of Conducted Electrical Weapons Used by Law Enforcement Officers Against
Criminal Suspects" Annals of Emergency Medicine 53: 480-489 (April 2009) A rapidly evolving body of literature
has examined a range of physiologic and cardiovascular effects of conducted electrical weapon exposure in human
volunteers. These studies, which include articles and published preliminary reports in abstract form, demonstrate no
evidence of dangerous respiratory or metabolic effects using standard (5-second), prolonged
(15-second), and extended (up to 45-second) conducted electrical weapon discharges. Other studies of conducted
electrical weapon exposure in combination with exercise designed to simulate the physiologic effects of fleeing from
or struggling with police demonstrate changes in pH, lactate, and other markers comparable to that induced by
exercise of the same duration. No study has demonstrated a pathophysiologic mechanism or effect that would
account for delayed deaths minutes to hours after conducted electrical weapon exposure. Findings from independent
investigations have been concordant with those performed with industry support. Collectively, these data are broadly
reassuring and constitute the current best understanding of the human physiologic effects of conducted electrical
weapons.

25

 The Extraction
In some cases, the presence of the SERT team dressed in all black or Tyvek can scare an
individual. So, in an effort to keep Ms. McKenna calm, Lt. Miller approached the cell by
himself at first.87 Lt. Miller stood at Ms. McKenna's cell door (FR-2) and explained that deputies
were there to move her out of her cell and take her to Alexandria. The cell Ms. McKenna
occupied was unfurnished and the only items inside were a suicide smock and a blanket. At that
moment Ms. McKenna appeared to Lt. Miller to be rational. He asked her if she would cooperate
and she said, "Line." It was Lt. Miller's goal to obtain Ms. McKenna's voluntary compliance
with the process and avoid the use of force. Based upon her response, he believed she would be
compliant. He asked her to put her arms out of the food slot so that he could hand cuff her. She
said "okay" and complied. Lt. Miller handcuffed her and applied the rip hobble to the handcuffs
so that Ms. McKenna could not withdraw her hands. However, Ms. McKenna pulled her hands
back into the cell causing Lt. Miller to tug the rip hobble outwards to avoid his fingers going
through the slot into the cell with Ms. McKenna. Lt. Miller then gave the rip hobble to Deputy
Davila so that he could summon the SERT team. He then radioed Lt. Salzman and the SERT
team arrived soon after.

oo

When the SERT team came down the hallway to Ms. McKenna's cell, Lt. Miller said,
"I'm going to open the door" and asked, "Is there a shield, just in case she... (inaudible)." He
then asked, "Do we have a Medic ready?"(l:27 video). Lt. Salzman relayed this request and
stated, "Can we get someone to get a nurse here to post four here to check her when we get her
out?" An unknown male voice replied, "Yes." The shield was passed to Deputy Perryman. Lt.
Miller took the rip hobble from Davila and unlocked the cell door (2:02 video). As he opened the

87 3/16/2015
88 Tr.

Report of Detective Farrell (quoting Deputy Henry)
2/6/2015 Salzman, p.28; Tr. 2/6/2015 Henry, p. 14

26

 door, Lt. Miller held on to the rip hobble. Ms. McKenna then came out of the cell, began moving
away, and stated, "You promised me you wouldn't kill me. I didn't do anything" (2:04 video).
Deputy Perryman used the shield to pin Ms. McKenna against the cell door (2:06 video). The use
of the shield in this manner was consistent with SERT Training.89 Lt. Miller instmcted SERT to
secure Ms. McKenna's legs.
Ms. McKenna began to resist by pulling away and refused to get on her knees. Ms.
McKenna remained on her feet flailing her legs. Lt. Miller instmcted SERT members to secure
Ms. McKenna's legs. Deputy McPartlin pulled her legs out from under her and took her to the
ground. Deputy Perryman then pinned her upper body against the open cell door with his shield
(2:34 video). Deputy Henry observed Ms. McKenna attempting to bite and claw the shield. One
team member held Ms. McKenna's head. Deputy McPartlin put his weight on her calf and this
enabled him to attach a leg restraint despite her continued resistance. Lt. Miller told Ms.
McKenna to stop resisting twice. Others on the SERT team repeated the command and added
"hold still Ma'am" and "lay there and obey all my commands" (2:51 video). Ms. McKenna
granted and said, "inaudible money" (3:08 video). Lt. Miller then said, "We're going to have to
put her on her belly." SERT Training requires inmates under the circumstance here to be placed
"face down on the floor."90
SERT members managed to get Ms. McKenna onto her stomach (4:06 video). The shield
was removed (4:10 video). While on the ground, Ms. McKenna continued to kick at SERT
members as they straggled to unclip the rip hobble from her handcuffs. The hobble was still
attached to the door and Ms. McKenna was using it to try to hoist herself back onto her feet,
even though it was cutting into her wrists. Deputy Henry tried to get Ms. McKenna to release her
89 Lesson

Plan Cover Sheet and Supplemental Pages (Revised January 8, 2009) Fairfax Criminal Justice Academy
*[pages not numbered]
90 Id

27

 grip on the rip hobble, and applied three closed fist strikes to her knuckles before she let go.
Once Ms. McKenna released the rip hobble, Deputy Henry was able to unclip the hobble from
the handcuffs. This action allowed Ms. McKenna's arms to drop and for SERT members to pin
them under the shield. Deputies' McPartlin and Krstulovic used their body weight to control her
legs. They then secured her ankles with the rip hobble. She continued struggling against the
deputies.
Lt. Miller told Ms. McKenna, in a calm voice, "Ma'am, Ms. McKenna, listen to me.
We're going to take you to Alexandria. Relax and let us put these handcuffs beside you and
we're going. Okay. Do you understand what I'm telling you?" She replied, "Yeah." Lt. Miller
responded by saying, "Well then quit combating with us okay?" He further stated, "We just need
to put these restraints away from... and have medical look at them. Please. Cooperate. Okay?"
(7:44 video).
At one point during the struggle, Lt. Salzman saw that the team needed more assistance
in holding Ms. McKenna's arms. He stepped in and placed his knee on Ms. McKenna's upper
left arm and placed his left hand on her arm as well. She began grabbing his fingers but could
not get a solid grip. He could feel her lifting his body up and down as he tried to keep his knee
on her arm. 91 Lt. Miller told Ms. McKenna, "Stop resisting. Cooperate. We are your friends.
We are here to help you" (10:46 video).
Lt. Salzman and others continued to urge Ms. McKenna to cooperate and stop resisting
but she continued to struggle. Lt. Salzman warned Ms. McKenna that, "If you continue to resist
we are going to use the TASER on you. Do you understand what that means?" (11:31 video).
Another team member stated, "Ma'am do you understand if you keep resisting you are going to
be tased?" Deputies continued to struggle for some time to get Ms. McKenna properly restrained.
91 Tr.

2/6/2015 Salzman, pp.53-54

28

 Lt. Salzman, then repeated, "Ma'am, stop resisting" (12:01 video). Ms. McKenna then made a
grunting sound and said, "Oh look at this inaudible is up my ass." Lt. Salzman said, "Stop
resisting." A few seconds later, Lt. Salzman said, "Ma'am If you continue to resist we are going
to have to tase you" (12:03 video). She continued to grunt and strain as Lt. Miller and SERT
attempted to secure her properly. Lt. Miller announced that nurses had arrived (14:04 video).
The SERT team attempted to remove Ms. McKenna's handcuffs in order secure her
hands to the transport belt. However, after doing so, they discovered that the transport belt gave
Ms. McKenna too much room to move her arms. She was able to position herself in a "push-up"
position and lift her body off of the floor. They then re-secured her wrists in the handcuffs but
behind her back this time. Lt. Salzman placed a spit mask over Ms. McKenna's head but did not
tie the strings on it (14:48 video).
The SERT team had intended originally to transport Ms. McKenna in a medic chair
(sometimes called an inmate wheel chair). The SERT team lifted Ms. McKenna to place her
onto the medic chair but she continued kicking, contorting, tensing her body and locking her
legs. This resistance prevented Deputies' McPartlin and Krstulovic, each of whom had one of
Ms. McKenna's legs, from securing her (15:24 video). SERT team members were able to
control Ms. McKenna's head to prevent her from injuring herself but could not get control of her
legs.
Lt. Miller asked Ms. McKenna to stop resisting and Lt. Salzman repeated the same
command (15:28 video). Lt. Salzman warned SERT members to watch out for Ms. McKenna's
hands and mouth (15:31 video). Realizing that they were not going to be able to secure Ms.
McKenna to the medic chair, Lt. Miller then said, "Where's the restraint chair. This is not going
to work. This is not going to work. Get the restraint chair." The team then put Ms. McKenna

29

 back on the floor (15:50 video). Lt. Miller leaned over Ms. McKenna and said, "How are you
doing Ma'am? Ms. McKenna, relax. How are you doing?"
Deputies rolled the restraint chair into position (16:34 video). SERT members begin to
move Ms. McKenna to the restraint chair (16:48 video). Lt. Miller took control of Ms.
McKenna's head and stated, "Watch her head. I got her head. I got her head." As she was placed
on the chair, Ms. McKenna thrashed her body and extends her legs outward (16:49 video). Lt.
Salzman said to Ms. McKenna, "Sit in the chair Ma'am." Ms. McKenna continued to strain,
grunt and resist efforts to secure her. At this point, Lt. Salzman warned Ms. McKenna that if she
did not sit in the restraint chair she would be tased (17:14 video). She continued to resist. Lt.
Salzman stated" I'm going to drive stun her if she keeps moving" (17:19 video). Lt. Salzman
removed the cartridge from the Taser and placed the Taser on her right upper leg and pulled the
trigger in drive stun mode one time holding it in place for five seconds. He deployed the Taser
in drive stun as a method of obtaining pain compliance in order to get her legs secured into the
chair.92
In response to this first drive stun Ms. McKenna sat back but relaxed only momentarily.
Deputy Henry was able to attach the waist belt by clipping it in. However, Ms. McKenna
continued struggling and pushing upwards preventing Deputy Henry from cinching the waist belt
tight.93
After the first deployment of the Taser, Lt. Salzman allowed Ms. McKenna time to
recover and comply with deputies. He said to Ms. McKenna, "Ma'am slide to the back of the
chair. Stop kicking your feet." Lt. Miller added, "Stop resisting. Don't kick. Don't kick. Trust

92 Tr.

2/6/2015 Salzman, pp. 52-53; Report of Autopsy N07-15 at p. 2 ("Two patterned square abrasions each
measuring 3/16" x 1/8" and separated by 1 1/2" of intact skin over the right superior anterior thigh without
underlying subcutaneous hemorrhage." See also Body Diagram.
93 3/16/2015 Report of Detective Farrell

30

 me. Don't kick. It's for your own good" (17:50 video). However, she continued twisting,
fighting, kicking and tensing her legs.
Lt. Salzman told Ms. McKenna, "slide to the back" (17:57 video). Lt. Miller implored
Ms. McKenna, "Let us put you in the chair please." She continued resisting. In light of the
ineffectiveness of the first Taser deployment, Lt. Salzman decided to re-deploy the Taser, this
time using the darts along with the drive stun. He intended to put both darts in her right leg and
press the Taser elsewhere on her body in order to get a greater spread and gain compliance. Lt.
Salzman announced, "Taser" (18:02 video). He fired the darts into her leg at close quarters
resulting in a very small spread between the two prongs.94 At that point, the Taser began cycling
(administering current). The Taser cycles for five seconds with each deployment. As the
countdown from five to zero began, Lt. Salzman realized that because of all the movement and
struggling, he would be unable to touch the Taser to Ms. McKenna for the full five seconds.
This meant that if he pressed the Taser against her body she would only have received the full
effect for a couple of seconds at most. Lt. Salzman did not want to administer Ms. McKenna an
arbitrary and unnecessary stun drive so he let the Taser cycle down without touching it to her
body.95 The darts are visible in Ms. McKenna's right thigh after the camera angle changes (18:20
video). After Lt. Salzman fired the Taser darts into Ms. McKenna's thigh, Deputy Henry was
able to cinch the waist belt tight.96 But once again Ms. McKenna continued to resist, twisting her
body and kicking out her legs (18:45 video).
Lt. Salzman then reassessed the situation. Again, he gave Ms. McKenna time to stop
resisting and recover. He also allowed deputies the opportunity to try to gain compliance now

94 Report of Autopsy N072-15, p. 2 (".. .2 1/16" puncture wounds separated by 7/8" of intact skin...") See also Body
Diagram (showing location of possible Taser dart site on upper right thigh)
95 Tr. 2/6/2015 Salzman, pp. 56-59
96 3/16/2015 Report of Detective Farrell; Tr. 2/6/2015 Henry, pp. 19-20

31

 that she had been tased a second time. Lt. Salzman attributed the relative ineffectiveness of the
second deployment of the Taser to the fact that, due to the continuing struggle, he was prevented
from touching the front of the Taser to a location on Ms. McKenna's body that was removed
from the darts. This resulted in the current going to the same spot with the same (small) spread
q7

as the first drive stun deployment.

Ms. McKenna continued to lock her legs, kick and struggle. Notwithstanding the fact that
Deputies McPartlin and Krstulovic had applied a rip hobble around her legs, Ms. McKenna was
still attempting to kick them. They remained unable to secure her legs to the restraint chair
straps.98
After waiting long enough to determine that Ms. McKenna remained noncompliant and
giving her sufficient time to recover, Lt. Salzman decided to drive stun Ms. McKenna in the
middle of her outside right bicep. He chose this location because it was a large muscle with a
good spread from where the darts were lodged in her thigh and wouldn't cross her heart. Lt.
Salzman planned to press the Taser on Ms. McKenna's right bicep first. Then, after it was set,
he would pull the trigger and deliver the full five second cycle in the hope that it would deliver a
full body lock up and allow an opportunity for the deputies to secure Ms. McKenna.99
Lt. Salzman placed the Taser against Ms. McKenna's outside right bicep and pulled the
trigger one time, letting it cycle for five seconds as he counted aloud from five to zero (19:18
video). When the Taser finished cycling, Lt. Salzman saw Ms. McKenna' body relax
momentarily.100 Deputy Henry noticed her leg loosen a little bit and he was able to get a leg strap

97 Tr.

2/6/2015 Salzman, p. 59
Report of Detective Farrell; Tr. 2/6/2015 Henry, p. 20
99 Tr. 2/6/2015 Salzman, p. 60
100 Tr. 2/6/2015 Salzman, p. 61
98 3/16/2015

32

 around but remained unable to cinch it tight before she again resumed resisting. 101 Lt. Salzman
stated," "Ma'am if you continue to resist you will be tased again" (19:26 video). The warning
had no effect on Ms. McKenna and she fought on. Ms. McKenna resumed resisting, kicking,
twisting, turning, contorting and locking her legs. The team was unable to secure Ms.
McKenna's legs to the chair.
Despite Ms. McKenna's continued resistance, Lt. Salzman realized that this last Taser
deployment had been somewhat effective insofar as it caused Ms. McKenna's body to relax for a
moment. He believed that if he could get her in that situation again, the team might be able to
hook her legs to the chair and end the lengthy struggle.102
Once more, Lt. Salzman gave Ms. McKenna time to recover and comply. Lt. Salzman
again applied the Taser Ms. McKenna's to upper outer right arm (20:00 video). Ms. McKenna
stated, "Ah I was going to fight back" (20:01 video)." Lt. Salzman counted aloud as the Taser
cycled down from five seconds so that the team would be ready to attempt to secure her when he
finished. As Lt. Salzman reached the count of zero, Ms. McKenna's body relaxed as expected.
For the first time the deputies were able to push her feet down and secure them. 103
Once Ms. McKenna was secured in the restraint chair, the SERT team's next goal was to
secure the waist belt down as it was up over her belly. The waist belt is supposed to be around
the hips. Ms. McKenna continued to resist using her feet, arching her back and pushing out with
her chest against the restraints. Deputies were able to lean Ms. McKenna forward and slide her
back in the seat. Lt. Salzman pulled down the waist restraint enough to allow her to be safely
transported.104 Nurses were standing by in the hallway for the purpose of checking on Ms.

101 Tr.

2/6/2015 Henry, pp. 20-21
2/6/2015 Salzman, p. 61
103 Tr. 2/6/2015 Salzman, p. 61-62
104 Tr. 2/6/2015 Salzman, p. 61-62
102 Tr.

33

 McKenna's welfare. Lt. Miller asked Nurse Abebe if she was ready to check on Ms. McKenna.
She replied, "Yes." Lt. Miller advised Nurse Abebe that Ms. McKenna had been tased four
times. Lt. Salzman showed the nurse each place on Ms. McKenna's body where he had applied
the Taser (21:48 video). Ms. McKenna continued to struggle and grunt. Nurse Abebe checked
Ms. McKenna's restraints. Nurse Abebe asked for help controlling Ms. McKenna. A SERT
member held Ms. McKenna with one hand on her neck/upper back area (21:50 video). Lt. Miller
asked Nurse Abebe if she wanted to take Ms. McKenna's vital signs. Nurse Abebe indicated she
would be unable to take Ms. McKenna's vital signs because she was struggling still. Lt. Miller
advised the nurse that they were going to move Ms. McKenna and questioned her as to when she
would take the vitals if not now. Ms. McKenna was moving her head and opening and closing
her legs at this time (22:23 video). Lt. Miller said, "Come on we're not stopping you." Nurse
Abebe conferred with someone off camera and Nurse Lamin wheeled the Welch Allyn machine
to the side of the restraint chair (22:57 video). Nurse Abebe placed the blood pressure cuff on
Ms. McKenna's right arm (23:25 video). Ms. McKenna's legs continued opening and closing
(23:20 video). Lt. Miller stated, "Ms. McKenna how you doing? How you doing?" There was no
audible response (22:32 video). Nurse Abebe appeared to press buttons on the Welch Allyn
machine which emitted two short beeps. As this occurred, Nurse Lamin was adjusting the blood
pressure cuff (23:47 video). Nurse Abebe asked Lt. Miller for a smock to cover Ms. McKenna
(24:21 video). The nurses cover Ms. McKenna with a suicide smock provided by deputies
(22:52 video). The Welch Allyn machine sounded two long beeps. The nurses then adjusted the
blood pressure cuff and Nurse Abebe pressed a button on the machine (25:03 video).
At this point Lt. Miller asked the nurses, "Everything cool? Or do we... ?" A female voice
said, "No." Ms. Abebe continued to adjust the blood pressure cuff as Lt. Salzman spoke with Lt.

34

 Perkins about how to best restrain Ms. McKenna during the transport (25:10 video). Lt. Salzman
stated, "We're going to do some adjustment of the restraints downstairs so we'll get the um her
all suited up with the smock and everything when we get down there" (25:29 of the video).
Lt. Perkins asked the nurses, "Which one of you is going to follow them on down?"
Nurse Lamin replied, "I'll follow"(25:38 video). Lt. Miller stated to the nurses, "Not getting
anything?" Lt. Miller then asked Ms. McKenna, "How you doing. How you doing Ms.
McKenna?" Ms. McKenna's then lifted her head and rested it on the back of the chair and
turned towards Lt. Miller (26:10 video). At that point the Welch Allyn machine sounded two
long beeps. Ms. McKenna was quiet at this point. (26:04 video) Ms. Lamin stated, "We cannot
get the inaudible.'" Lt. Perkins asked, "Are we good to go?" Nurse Abebe responded, "Yeah"
(26:21 video). Deputies then wheeled Ms. McKenna to the elevator (26:48 video).
Ms. McKenna was taken directly from the elevator to the sally port. Once in the sally
port, Lt. Salzman removed the probes (also referred to as darts) from Ms. McKenna's legs and
asked the nurse if she could now check Ms. Mckenna's vitals (31:19 video). Nurse Lamin
stepped in and began to try to attach the cuff from the Welch Allen machine to Ms. McKenna's
right arm (31:26 video). She was unable to do so and moved to Ms. McKenna's left arm (32:08
video). She got the cuff attached to Ms. McKenna's left arm (32:32 video). Nurse Lamin then
spent the next two minutes and approximately ten seconds looking at the machine, adjusting the
cuff and feeling for Ms. McKenna's pulse with her fingers while looking at her watch. She then
said, "It's not taking" (34:11 video). The deputies called Ms. McKenna's name and lifted the
spit mask (34:16 video). A deputy stated, "Check her pulse" (34:21 video). Lt. Miller asked,
"Do you have anything?" (34:23 video). Nurse Lamin replied, "No." Nurse Lamin then reached
down by Ms. McKenna's left side with her right hand. Lt. Miller asked her, "What do you

35

 want?" (34:25 video). Nurse Lamin placed her right hand near Ms. McKenna's left and then
right clavicle (34:27 video). Nurse Lamin then reached for the Welch Allyn machine with her
right hand and pressed a button. The machine made two short beeps (34:33 video). Lt. Miller
asked the nurse, "What do you got?" (34:36 video). Nurse Lamin's reply was inaudible (34:37
video). Lt. Miller then said, "Do you want us to call rescue?" She responded "all right." Lt.
Miller then stated, "Call rescue." A female voice can be heard on the video repeating, "Call
rescue." Nurse Lamin placed her left hand on Ms. McKenna's upper chest and began
performing compressions. She then moved her hand to Ms. McKenna's mouth (35:24 video).
Then she returned to performing one handed compressions on Ms. McKenna's chest (35:31
video). Deputies removed the restraints and lifted Ms. McKenna out of the chair to the floor
(36:02 video). A male deputy announced, "We're starting CPR right now." Sgt. Mason applied
the first of two AED pads to Ms. McKenna's upper right chest (36:41 video). The nurse began
performing two handed CPR on Ms. McKenna's abdomen area (36:46 video). Sgt. Masson
applied the second AED pad to Ms. McKenna's left chest (36:51 video). The AED was
employed and no shock was advised (37:00 video). Nurse Lamin resumed two handed
compressions on Ms. McKenna's abdomen (37:20 video). Pfc. David Trader took over chest
compressions from Ms. McKenna's left side (37:29 video). Pfc. Trader administered rescue
breathing to Ms. McKenna (38:08 video). He then alternated between doing chest compressions
and giving rescue breaths (38:18 - 39:15 video). Once again the AED was employed but no
shock was advised (39:27 video). Sgt. Mason then relieved Pfc. Trader and began chest
compressions himself (39:43 video). Lt. Miller began administering rescue breaths (40:04
video). Pfc. Trader resumed chest compressions, relieving Sgt. Mason (40:09 video). Rescue
arrived (40:40 video). A member of rescue asked, "Are any exposures here that we got to worry

36

 about?" Lt. Salzman replied that Ms. McKenna was bleeding from the wrist. The rescue squad
member asked about the need for Tyvek suits and respirators by the deputies. Lt. Salzman can
be heard to respond, "Not that we know of." Lt. Salzman gave rescue the information that Ms.
McKenna was fighting with deputies for fifteen or twenty minutes and was tased four times
during the incident (41:29 - 42:17 video). The AED was deployed again but no shock was
advised and Sgt. Mason resumed chest compressions (41:50-42:06 video). Rescue then attached
an automated CPR machine to Ms. McKenna and took over from deputies. Rescue placed Ms.
McKenna into the ambulance and exited the sally port (43:05-46:10 video). Lt. Taggart stopped
recording the events (46:25 video).
Deputies involved in this struggle with Ms. McKenna were struck by the strength and
endurance demonstrated by Ms. McKenna. Again, extreme even "super human" strength is a
well-documented symptom of excited delirium syndrome. 105 Lt. Miller said, "... She was
literally pushing the guys around. I mean there was one guy to each leg and they were not
succeeding in getting the restraint... Very strong and she wouldn't cooperate." 106 In describing
Ms. McKenna's incredible strength, Deputy Henry said, ".. .she was.. .pushing us up almost like
doing a pushup and she was actually pressing four of us up off the ground which was
astonishing." 107 Deputy McPartlin recalled, ".. .she was fighting us which was a hell of a fight
even though she had leg restraints..."

1 CVQ

Lt. Taggart, the cameraman, stated, "She put up

a.. .bigger fight than I've seen a lot of men do.. .fighting back against the SERT guys.. .1
mean.. .some of those guys are not little guys.. .but they were having trouble getting her under

105 White

Paper Report on Excited Delirium Syndrome, ACEP Excited Delirium Task Force, American College of
Emergency Physicians, September 10, 2009 pp. 7-8 ("super human strength")
106 Tr. 2/6/2015 Miller, p. 25
107 Tr. 2/6/2015 Henry, p. 17
108 Tr. 2/6/2015 McPartlin, p.12

37

 control."109 Deputy Krstulovic stated, "We struggled with her for a long, long time. I don't
think I've ever struggled with anyone that long before...and I've been doing this for a long, long
time and that was one of the hardest cell extractions I've ever come across." 110

Ms. McKenna's Hospitalization 2/3/2015 - 2/8/2015
Ms. McKenna arrived at INOVA Fairfax Hospital unconscious, unresponsive, intubated
and ventilated.111 She was admitted to the hospital in PEA arrest with lactic acidosis and
hyperthermia. Staff resuscitated her after one hour of CPR. Her hospital course was
complicated by anoxic brain injury, acute hypoxic respiratory failure, acute kidney injury,
rhabdomyolysis, shock liver and diabetes insipidus 112 Dr. Andrew Forgash III treated Ms.
McKenna in the emergency room. His differential diagnosis was "excited delirium, sudden
cardiac death."113
Physicians and staff at Fairfax Hospital performed numerous medical procedures in an
attempt save Ms. McKenna's life. However, on February 7, 2015, Doctors Busse and Putnam
declared Ms. McKenna brain dead.114 The following day, Ms. McKenna was taken off critical
care interventions. Cardiac standstill followed and Ms. McKenna's body was transferred to the
Morgue for follow up by the Medical Examiner. 115

109 Tr.

2/7/2015 Taggart, pp. 47-48
2/6/2015 Krstulovic, p. 32
111 ED Notes INOVA Fairfax Hospital 2/3/15 (Generated on 3/23/2015 p. 339)
112 Report of Autopsy N072-15
113 ED Notes INOVA Fairfax Hospital 2/3/15 (Generated on 3/23/2015 p. 341); Report of Autopsy N072-15
114 Inpatient Record INOVA Fairfax Hospital 2/7/15 (Generated on 3/23/2015 p. 552)
115 Inpatient Record INOVA Fairfax Hospital 2/08/15 (Generated on 3/23/2015 p. 558-559)
110 Tr.

38

 Operation, Function and Deployment of the ECW
For the purpose of understanding the nature and effect of each deployment of the ECW in
this matter, some explanation regarding the operation and function of the ECW (TASER X26) is
necessary. A single pull and release of the trigger on the TASER X26 used in this case
discharges an electrical charge for a 5-second cycle. Holding the trigger continuously beyond the
5-second cycle will continue the electrical discharge until the trigger is released. The discharge
will cease once the trigger is released after the 5-second cycle. It is important to note that the
mere fact that the ECW is activated and discharges for the full 5 second cycle does not mean that
the electrical discharge is necessarily fully delivered into the subject's body.
Both the downloaded data from the ECW, as well as the independent examination of the
ECW by W D Forensics Inc. confirm that in each instance here, Lt. Salzman pulled and released
the trigger thus activating the minimum, 5 second, electrical discharge.116
The TASER X26 may be operated in any of three ways; drive stun mode, probe mode or
combination probe/drive stun mode. In the drive stun mode the operator places the ECW in
direct contact with the subject and pulls the trigger. This may cause electric energy to enter the
subject directly. Drive stun mode is frequently used as a non-incapacitating pain compliance
technique. 117 The Drive stun mode is not a recommended manner of deployment, in most
instances, because it does not result in effective neuromuscular incapacitation (NMI). The small
spread between the fixed electrodes on the device results in only a localized electrical discharge.
There must be a spread of at least 4" for some neuromuscular incapacitation. 118

116 Forensic

Analysis Report, WD Forensic Inc. p.l; Taser Information Downloaded by Phillip Bender FCSO
Electronic Control Weapons Guidelines, by USDOJ and PERF at p. 42
118 Ho J, Dawes D, Miner, J, Kunz S, Nelson R, Sweeney J. Conducted electrical weapon incapacitation during a
goal-directed task as a function of probe spread. Forensic Sci Med Pathol. Apr 2012.

117 2011

39

 Lt. Salzman first employed the Taser in drive stun mode. Here the pattern injury,
reflecting this drive stun to Ms. McKenna's thigh shows a spread of only 1 1/2" well short of the
4" necessary to achieve neuromuscular incapacitation. The primary function of the drive stun
mode when not used to complete the circuit is to gain subject compliance through the
administration of pain. In the case here, because the deployment of the ECW in drive stun mode
was ineffective, Lt. Salzman attempted to re-deploy the Taser in combination drive stun/ probe
mode. The drive stun mode may be used in conjunction with the probe mode so as to induce
neuromuscular incapacitation.
In this mode, the drive stun is pressed against the subject once the probes have been
deployed into another area of the body. This is done so as to create a sufficient spread and thus
increase the effectiveness of the device. Here, Lt. Salzman deployed the probes into Ms.
McKenna's leg but was unable to complete the circuit by touching the ECW to her arm before
the device cycled down. The result was that the second deployment of the ECW was in probe
mode only. The deployment of the TASER X26 in probe mode, where there is an inadequate or
small spread between the probes in the skin is of limited effectiveness and fails to produce
effective neuromuscular incapacitation. In the present case, the probe spread was only 7/8 .
Thus, the second deployment of the ECW was no more effective than the first.
On the third attempt, Lt. Salzman was able to employ the ECW in combination drive
stun/probe mode by touching the ECW to Ms. McKenna's right arm and thereby completing the
circuit with the probes in her leg. This was more effective and enabled deputies to secure a strap
to Ms. McKenna's leg but they were still unable to secure her leg restraints to the chair. Upon
observing this, Lt. Salzman decided to employ it again whereupon deputies were able to finally

40

 secure Ms. McKenna's leg restraints to the chair and end the struggle. Notably, it was only
during these last two deployments that the ECW had any reckonable effect on Ms. McKenna.

Examination of the ECD (Taser Model X26)
On February 3, 2015, at 14:55:25 hours, Deputy Phillip Bender downloaded the data
from the Taser X26, serial # X00-717170, and generated a report. The report showed one 3
second long spark test of the Taser at 15:25:35 GMT (10:25:35 a.m.) and 4 more discharges of 5
seconds each as reflected in the chart below:
Seq

GMT Time

Local Time

Duration

Temp

Battery

Incomplete Time Change Record

0001
0002

05/23/13 16:24:57

05/23/13 12:24:57

Old Time

0003

05/23/13 16:24:57

05/23/13 12:24:57

New Time

0004

06/18/13 11:01:13

06/18/13 07:01:13

Old Time

0005

06/18/13 11:00:34

06/18/13 07:00:34

New Time

0006

02/03/15 15:25:35

02/03/15 10:25:35

3

23

88

0007

02/03/15 16:16:11

02/03/15 11:16:11

5

37

88

0008

02/03/15 16:16:50

02/03/15 11:16:50

5

37

87

0009

02/03/15 16:18:04

02/03/15 11:18:04

5

39

87

0010

02/03/15 16:18:49

02/03/15 11:18:49

5

39

87

0011

02/03/15 19:58:56

02/03/15 14:58:56

Old Time

0012

02/03/15 19:43:18

02/03/15 14:43:18

New Time

 Detectives, after consultation with the Commonwealth's Attorney, sent the Taser Model
X26 serial # X00-71710 along with the expended Taser cartridge, serial # C21011C3H, and
probes with attached wires to W D Forensic, Inc. of Seattle Washington for expert analysis.
Forensic scientists at W.D. Forensics determined that the Taser in question "functioned properly
as received with electrical output parameters within manufacturer's specifications."119 In
addition, "The Taser operated within Taser International specifications related to the parameters
of main phase charge, peak loaded main phase voltage, pulse duration, and pulse rate."120
The forensic examiners further opined, "Based on review of the submitted documentation
and forensic examination of the receive items, it was concluded that the evidence observe
supports the 20 second duration retrieved from the firing data on the Taser device related to the
incident date (February 3, 2015).121 The chart below is taken from the forensic report and
reflects the time and duration of each Taser discharge (adjusted for Seattle-Pacific time).
Local Time
[DD:MM:YYYY
hh:mm:ss]

Event
[Event
Type]

Temp
Duration
[Degrees
[Seconds]
Celsius]

Batt
Remaining
[%]

45

03 Feb 2015
07:25:35

Trigger

3

23

88

46

03 Feb 2015
08:16:11

Trigger

5

37

88

47

03 Feb 2015
08:16:50

Trigger

5

37

87

48

03 Feb 2015
08:18:04

Trigger

5

39

87

49

03 Feb 2015
08:18:49

Trigger

5

39

87

Seq
#

119 Forensic
120 Id

Analysis Report, WD Forensic Inc. p.l

p.3

42

 The lab analysis of the Taser X26 used in this event indicated that there were no
significant defects, i.e., charring or pitting, on the cartridge terminals. This indicates that the
majority of the electrical discharge occurred strictly at the probes in Ms. McKenna's thigh and
little if any current passed from the probes embedded in her thigh to the cartridge terminals on
her arm. 122 None of the four deployments of the ECW in this case would have likely resulted in
full neuromuscular incapacitation.123
According to recommendations made in the 2011 Electronic Control Weapon Guidelines
produced by the United States Department of Justice in cooperation with the Police Executive
Research Forum Guidelines Personnel should use an ECW for one standard cycle (five seconds)
and then evaluate the situation to determine if subsequent cycles are necessary. Personnel should
consider that exposure to the ECW for longer than 15 seconds (whether due to multiple
applications or continuous cycling) may increase the risk of death or serious injury. Any
subsequent applications should be independently justifiable and the risks weighed against other
force options.
On its face, Lt. Salzman complied with this recommended guideline. He deployed the
ECW in four separate instances for a duration of five seconds each. He re-evaluated the situation
between each deployment and determined an independently justifiable basis for each use based
upon Ms. McKenna's continued resistance among other factors. Given the close spreads on the
first two ECW deployments of 1 VC (drive stun mode) and 7/8" (probe mode), as well as the
third and fourth combination drive stun/probe mode deployments, where little if any electrical
discharge passed between the probes in Ms. McKenna's thigh and the cartridge on her arm, Ms.

122 Forensic

Analysis Report, WD Forensic Inc. p.l
with R. T. Wyant M.S. W D Forensic, Inc.

123 Consultation

43

 McKenna was never subjected to even one full, effective neuromuscular incapacitating
deployment of the ECW.

The Taser X26 Manual
The TASER X26 manual provides a number of safety warnings intended to minimize
hazards associated with ECD employment. Among these warnings are the following:

E3»

Physiologic or Metabolic Effects
The ECD can produce physiologic or metabolic effects which include, but are not limited to,
changes in: acidosis; adrenergic states; blood pressure; calcium, creatine kinase ("CK");
electrolytes (including potassium), heart rate and rhythm; lactic acid; myoglobin; pH;
respiration; stress hormones or other biochemical neuromodulators (e.g., catecholamines).
Reasonable effort should be made to minimize the number of ECD exposures and resulting
physiologic and metabolic effects. In human studies of electrical discharge from a single ECD
of up to 15 seconds, these effects on acidosis, CK, electrolytes, stress hormones, and
vital signs have been comparable to or less than changes expected from physical
exertion similar to struggling, resistance, fighting, fleeing, or from the application of
some other force tools or techniques. Adverse physiologic or metabolic effects may
increase risk of death or serious injury. (Emphasis added)

Higher Risk Populations
ECD Use on a pregnant, infirm, elderly, small child, or low body-mass index (BMI) person
could increase the risk of death or serious injury. ECD Use has not been scientifically tested on
these populations. The ECD should not be Used on members of these populations unless the
situation justifies possible higher risk of death or serious injury.

i

Physiologically or Metabolically Compromised Persons
Law enforcement personnel are called upon to deal with individuals in crises that are often
physiologically or metabolically compromised and may be susceptible to arrest-related death
("ARD"). The factors that may increase susceptibility for an ARD have not been fully
characterized but may include; a hypersympathetic state, autonomic dysregulation, capture
myopathy, hyperthermia, altered electrolytes, severe acidosis, cardiac arrest, drug or alcohol
effects (toxic withdrawal, sensitization to arrhythmias, etc.), alterations in brain function
(agitated or excited delirium), cardiac disease, pulmonary disease, sickle cell disease, and
other pathologic conditions. These risks may exist prior to, during, or after law
enforcement intervention or ECD Use, and the subject may already be at risk of death or
serious injury as a result of pre-existing conditions, individual susceptibility, or other
factors. In a physiologically or metabolically compromised person any physiologic or
metabolic change may cause or contribute to death or serious injury. Follow your
agency's Guidance when dealing with physiologically or metabolically compromised
persons. (Emphasis added)

44

 Excited Delirium Syndrome
In the seminal book, Excited Delirium Syndrome, Cause of Death and Prevention,
authors Theresa G. Di Maio and Dr. Vincent J.M. Di Maio describe excited delirium syndrome
as follows:
Excited delirium syndrome involves the sudden death of an individual,
during or following an episode of excited delirium, in which an autopsy fails
to reveal evidence of sufficient trauma or natural disease to explain the death.
In virtually all such cases, the episode of excited delirium is terminated by a
struggle with police or medical personnel, and the use of physical restraint.
Typically, within a few to several minutes following cessation of the
struggle, the individual is noted to be in cardiopulmonary arrest. Attempts at
resuscitation are usually unsuccessful. If resuscitation is "successful," the
individual is found to have suffered irreversible hypoxic encephalopathy and
death occurs in a matter of days. 124

Relying on symptomology long observed in the medical community, Dr. Di
Maio opined, "Death occurring from excited delirium syndrome, whether due to intrinsic
mental disease or use of stimulants, is characterized by:
•
•

Acute onset of symptoms (minutes to hours)
Delirium with acute, transient disturbance in consciousness or cognition;
disorientation; disorganized and inconsistent thought processes; inability
to distinguish realty from hallucinations; disturbances in speech;
disorientation to time and place; misidentification of individuals
• Combative and/or violent behavior
• Use of physical restraint
• Sudden cardiac death within minutes to hours after development of
symptoms
• Lack of response to cardiopulmonary resuscitation (CPR)
• A history of either stimulant abuse or endogenous mental disease" 125

124 Di

Maio Theresa G. and Di Maio, Vincent J.M., Excited Delirium Syndrome Cause of Death and Prevention
(CRC Press 2006) p. 1
125 Di Maio Theresa G. and Di Maio, Vincent J.M., Excited Delirium Syndrome Cause of Death and Prevention
(CRC Press 2006) p. 18 citing Bell, L. V., On a form of disease resembling some advanced stages of mania and
fever. Am. J. Insanity 6: 97-127, 1849

45

 In 2008, the American College of Emergency Physicians (ACEP) formally adopted
Amended Resolution 21(08) which created a task force and instituted a formal study into the
existence, or not, of excited delirium syndrome. One year later, on September 10, 2009, the
Excited Delirium Task Force published a White Paper recognizing excited delirium as a "unique
syndrome which may be identified by a distinct group of clinical and behavioral characteristics
that can be recognize in the per-mortem state..."

10f\

Most persons suffering from excited delirium are hyper-aggressive, impervious to pain,
and demonstrate unusual, "superhuman," strength. They engage in a lengthy period of stmggle,
followed by a period of quiet and sudden death. 127 "Severe Acidosis appears to play a
prominent role in lethal [excited delirium] ExDS associated cardiovascular collapse." 128
The ACEP Task Force concluded that, "it is the consensus of the Task Force that ExDs
[excited delirium syndrome] is a real syndrome of uncertain etiology. It is characterized by
delirium, agitation, and hyper-adrenergic dysfunction, typically in the setting of acute or chronic
drug abuse or serious mental illness." 129 The report went on to note that, "There are welldocumented cases of ExDS deaths with minimal restraint such as handcuffs without ECD
(Electrical Conductive Device) use. This underscores that this is a potentially fatal syndrome in
and of itself..." 130
In Excited Delirium Syndrome Cause of Death and Prevention, the authors concluded
that "death in the excited delirium syndrome results from a fatal cardiac arrhythmia due to a
hyper-adrenergic state caused by:

126

White Paper Report on Excited Delirium Syndrome, ACEP Excited Delirium Task Force, American College of
Emergency Physicians, September 10, 2009 p. 1
127 White Paper Report on Excited Delirium Syndrome, ACEP Excited Delirium Task Force, American College of
Emergency Physicians, September 10, 2009 pp. 3, 7-8,
128 Id. p. 13
129

W „

46

 1. The excited delirium, which in itself triggers release of catecholamine
2. Additional release of catecholamines due to the struggle
3. A rapid and steep drop in blood potassium concentrations following cessation of the
struggle in association with increasing levels of catecholamines.

131

The Autopsy
On February 9, 2015, Dr. Jocelyn Posthumus, M.D., a forensic pathologist with the
Office of the Chief Medical Examiner performed an autopsy upon the body of Natasha J.C.
McKenna. It reads in pertinent part as follows:
CASE SUMMARY:
According to investigators and medical records, this was a 37-year-old
African American female with a past medical history of schizophrenia and bipolar
disorder who went unresponsive after an approximately 45 minute extraction
from her jail cell. Review of the police video and reports show that the decedent
was combative requiring the use of physical restraint, leg restraints, handcuffs,
rip hobble and spit hood while they attempted to place her into a restraint chair.
She continued to resist and a conducted energy device (CED) was deployed four
times in a span of approximately 2 minutes using the drive stun three times (once
into the right thigh and twice into the right upper arm) and the cartridge once
(right thigh). After the fourth CED deployment, the decedent stopped resisting
and she was transported from her cell to the Sally port area secured to the
restraint chair by a waist belt and leg restraint still wearing the spit hood with
her hands secured in handcuffs behind her back. Once in the Sally port area the
decedent was found unresponsive and asystolic. She was admitted to the hospital
in PEA arrest with lactic acidosis (pH of 6.68) and hyperthermia (100°F) and
was resuscitated after one hour of CPR. Her hospital course was complicated by
anoxic brain injury, acute hypoxic respiratory failure, acute kidney injury,
rhabdomyolysis, shock liver and diabetes insipidus.
Gross and microscopic examinations showed puncture wounds consistent
with the use of CED darts over the right anterior thigh. There were scattered
superficial and deep blunt force injuries to the extremities and torso consistent
with the history of physical restraint. There was no evidence of underlying
cardiovascular or neurologic disease. Toxicological analysis of hospital serum
was positive for a non-toxic level of aripiprazole (49 ng/mL).

131 Di

Maio Theresa G. and Di Maio, Vincent J.M., Excited Delirium Syndrome Cause of Death and Prevention
(CRC Press 2006) p. 72

47

 The decedent had two recent hospital admissions on 01/08/2015 and
01/15/2015 for altered mental status with aggressive behavior and was diagnosed
with lactic acidosis, leukocytosis and rhabdomyolysis with a negative urine drug
screen. On both admissions she was brought to the hospital by police with
documented use of restraint and pepper spray on the latter occasion.
The decedent was in a state of profound agitation/psychosis during the extraction
and the use of physical restraint with or without CED use is associated with
sudden death. Excited delirium occurs in the setting of stimulant drug abuse,
psychiatric disease, psychiatric drug withdrawal and metabolic disorders and is
characterized by psychosis and agitation and is often associated with
combativeness and elevated body temperature. (Emphasis added)
CAUSE OF DEATH:
Excited delirium associated with physical restraint including use of
conducted energy device
CONTRIBUTING:
Schizophrenia and bipolar disorder
MANNER OF DEATH:
Accident
PATHOLOGIST:
Jocelyn Posthumus. M.D.
DECEDENT:
Natasha JC McKenna132

Conclusion
My legal analysis as to whether the actions of the involved deputies could constitute a
criminal act was guided by applicable case law and legal precedent on the use of force by law
enforcement. To be lawful, a deputy's use of force must be objectively reasonable in light of all
of the facts and circumstances confronting the deputy. Whether such actions were reasonable is
evaluated from the perspective of a reasonable deputy at the scene rather than the 20/20 vision of
hindsight. As the United States Supreme Court has explained, "[T] he calculus of reasonableness
must embody allowance for the fact that police officers are often forced to make split-second
132 Report

of Autopsy N072-15 p. 4

48

 judgments-in circumstances that are tense, uncertain, and rapidly evolving- about the amount of
force that is necessary in a particular situation." Graham v. Connor, 490 U.S 386 (1989).
On the evidence here, I conclude that SERT members and deputies acted lawfully and
reasonably under the circumstances in attempting to restrain and control Ms. McKenna. The
deputies were tasked with a cell extraction involving a severely mentally ill woman with a
history of recent violence and resistance towards police officers, deputies and medical personnel.
Ms. McKenna's recent combative behavior included biting, scratching, spitting, kicking and
punching. Everyone who dealt with her in these instances, medical personnel as well as police
and deputies, described her as being exceptionally strong, irrationally combative and seemingly
indefatigable. Further complicating the task confronting these deputies was Ms. McKenna's
creation of a bio hazard with her feces and urine as well as her positive status for herpes 133 and
MRSA134 both highly contagious diseases.
These deputies found themselves in a protracted and violent struggle with Ms. McKenna.
There is no evidence that any of the deputies acted maliciously, sadistically or with the intent to
punish or cause harm to Ms. McKenna at any point in the struggle. To the contrary, they did their
best, under very difficult circumstances, to restrain, control and prevent Ms. McKenna from
injuring herself or others.
The Medical Examiner's Report of Autopsy concludes that the manner of Ms.
McKenna's death was accidental and was caused by excited delirium associated with physical
restraint including use of conducted energy device, along with the additional contributing factors
of schizophrenia and bipolar disorder.

133 Forensic

Intake Interview on 1/27/2015 Fairfax Fall Church CSB, p.2.
Provider Notes; INOVA Fairfax Hospital Encounter Notes on 02/06/2015 (Generated on 3/23/2015) p. 498;
It is not clear whether the MRSA came before or during Ms. McKenna's final hospitalization.
134 ED

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 As the Medical Examiner explained in her report, "Excited delirium occurs in the setting
of.. .psychiatric disease ... and metabolic disorders and is characterized by psychosis and
agitation and is often associated with combativeness and elevated body temperature..." In
situations involving individuals suffering from excited delirium syndrome, "the use of physical
restraint with or without CED use is associated with sudden death."

135

There is no question but that Ms. McKenna suffered from serious psychiatric disease and
that she exhibited all of the classic symptoms of excited delirium syndrome. The attestations of
numerous witnesses to the events of February 3, 2015, as well as the video of the extraction,
demonstrate that Ms. McKenna was agitated and combative with deputies for a lengthy period.
The restraining methods used by deputies in an effort to protect Ms. McKenna and themselves
were appropriate based on the facts as the deputies perceived them. Furthermore, Ms.
McKenna's death cannot be attributed to any particular single restraint tactic employed that day,
including deployment of the Conductive Energy Device (CED). Tragically, it was Ms.
McKenna's metabolically unsustainable and protracted resistance to any restraint due to her
mental illness and the ensuing excited delirium syndrome that actually caused her death. As
noted by Dr. Di Maio, "If death is due to ventricular fibrillation or asystole produced by the
Taser pulse, then the individual would lose consciousness immediately (3 to 4 seconds up to a
maximum of 10 to 15 seconds)." Ms. McKenna was conscious for several minutes after the last
deployment of the Taser. This is wholly inconsistent with cardiac pulmonary arrest due to a
Taser shock but entirely consistent with cardio pulmonary arrest resulting from excited delirium
where, " [t]ypically, within a few to several minutes following cessation of the struggle, the

135 Report

of Autopsy N072-15 p. 4

50

 individual is noted to be in cardio pulmonary arrest."

136 This

is precisely what happened in this

case.
Moreover, the medical records from Ms. McKenna's final hospitalization confirm that
Ms. McKenna suffered from the potentially lethal abnormal body chemistry associated with
death caused by excited delirium. She was admitted to the hospital in PEA arrest with lactic
acidosis and hyperthermia. She suffered from anoxic brain injury, acute hypoxic respiratory
failure and rhabdomyolysis. The treating physician, Dr. Forgash, arrived at a differential
diagnosis of "excited delirium, sudden cardiac death." 137 His diagnosis of excited delirium was
confirmed by the Medical Examiner who performed the autopsy on Ms. McKenna's body. In the
end, it was Ms. McKenna's severe mental illness, coupled with the tremendous physical exertion
she put forth over an extended period of time struggling with deputies that resulted in a cascade
of lethal chemical reactions inside of her body.
Ms. McKenna's death was a tragic accident. It is my legal opinion that there is not
probable cause, much less proof beyond a reasonable doubt, that anyone involved in this case
committed a crime.

Date:

136 Di

Maio Theresa G. and Di Maio, Vincent J.M., Excited Delirium Syndrome Cause of Death and Prevention
(CRC Press 2006) p. 1
137 ED Notes INOVA Fairfax Hospital 2/3/15 (Generated on 3/23/2015 p. 341); Report of Autopsy N072-15

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