New Book: Guidelines For Investigating OISs, ARDs & Custody Deaths

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When it comes to suspects who die in law enforcement settings, street cops, investigators, administrators, police lawyers, and medical examiners can probably all agree on one thing: investigating such events, in the words of one research team, is a “perilous and a slippery slope.”

An excellent new book—Guidelines for Investigating Officer-Involved Shootings, Arrest-Related Deaths, and Deaths in Custody—is designed to make that challenging task less fraught, the outcome more reliable, and, to the extent possible, the occurrence itself less controversial and contentious.

Its 300+ pages of tightly packed, practical reports of the latest relevant research findings and recommended procedures are likely to become a bible for law enforcement stakeholders who are fated to deal with the hot-button title topics while under great public pressure and scrutiny.

Lead author/editor is Darrell Ross, who shares the book’s byline with colleague Gary Vilke. Ross, whose research studies are well known to Force Science News readers, is a PhD and CJ department head who directs the Center for Applied Social Sciences at Valdosta (GA) State University. Vilke, a physician, is a professor in the emergency medicine department at the University of California-San Diego who has extensively researched in-custody deaths.

Fifteen other high-cred contributors, including some Force Science associates, have produced chapters for this unique volume, ranging from essentials that investigators need to know about the effects of stress on decision-making and memory to how an agency can most effectively respond to the media regarding use-of-force incidents.

Collectively, Ross says, the contributors, all working practitioners, “have provided expert witness services in over 2,000 cases on all the varying topics addressed in the book.” Their commentaries contain instructive case examples and lessons learned, sometimes through painful personal experience.


A law enforcement-related death is a rare occurrence, Ross points out—so rare, in fact, that it is likely to be a once-in-a-career experience for everyone involved, from field officers to medical examiners. Add to that unfamiliarity the forensic complexity and relentless stress of a high-profile investigation and you have a recipe for much that can go wrong.

“Performing an investigation in any one of these types of death…requires current knowledge and skills in numerous disciplines and techniques,” Ross writes. “Errors can significantly impact the ultimate outcome, so getting it right is of utmost importance.”

Toward that end, Guidelines offers in layman’s language:

  • focused insights into the nature of these deaths,
  • the numerous and often misunderstood investigatory issues that tend to emerge,
  • current scientific research findings pertinent to each topic area,
  • a specific, comprehensive “framework of actions, considerations, and activities” required to perform “competent, productive, and thorough investigations,” and
  • vital checklists of proper protocols to assure that nothing is missed as the investigation proceeds to resolution.

Each of the book’s 16 chapters concludes with extensive lists of additional resources where even more information on each given subject can be accessed.

Here’s how the volume unfolds:


The first five chapters lay a fundamental groundwork for an investigator approaching the special circumstances of a suspect’s death, potentially the most challenging assignment he or she will ever draw.

Ross and colleagues explain in detail the expectations of the various concerned parties, including the department, the involved officer(s), the deceased’s family, the criminal justice system, and the investigator himself. And they itemize some 30 “emergent questions” that will need to be addressed, as well as 10 common “failures” that can lead to incomplete or wholly erroneous conclusions.

Legal and liability issues relevant to criminal, civil, and administrative aspects of an investigation are reviewed in detail. “Failure to be aware of these legal distinctions could severely damage the investigation,” Ross writes, “while understanding the law and procedures will assist in ensuring the evidence obtained will not be suppressed in future proceedings.”

When a suspect has died in a shooting or other use-of-force event, it will also be critically important for an investigator to understand the mental state of the involved officer(s) at the time of the encounter. Here Ross and a combat stress researcher (Randall Murphy) thoroughly describe “the science of the stress response,” providing a roundup of ground-breaking peer-reviewed findings about the impact of stress on officer performance and offering a useful “human factors checklist.” Dr. Bill Lewinski, executive director of the Force Science Institute, is among the experts cited.

Guidelines includes a full chapter on “Memory and Decision Making Under Stress” by Force Science instructor Dr. Alexis Artwohl. She explores 20 “key findings” about how decisions are made and actions recalled, including the fact that investigators themselves may fall victim to their own mental vagaries.

It’s important for investigators to become familiar with scientific research, Ross writes, “to gain a better understanding for the limits of human performance.” That will provide them “better guidance in conducting the investigation and preparing to interview the involved officer.”

(Investigators and other interested parties, of course, can also keep abreast of the latest scientific findings on human behavior under stress by checking regularly with the Force Science website at: www.forcescience.org.)


A successful investigation starts before there’s a need for it, Ross points out in Chapter 6, which serves as a keystone for the book.

Beginning with policies, training, and pre-incident planning, Ross and a police chief (Mark Dunston) walk you through the proper investigative process, including protocol and procedures for dealing with the involved officer, the scene, the scene supervisor, the agency administrator, witnesses, communications evidence, medical documentation, the autopsy, the investigator’s report, even notification of the suspect’s survivors.

Forms and checklists abound. These range from a “Sudden Arrest-Related Death Investigation Form” to an “Officer-Involved Shooting Checklist” to a “Force Investigation Team Investigation Checklist”—all designed to help investigators “cross-reference their work” and “mitigate potential errors.”


Next, Guidelines addresses a series of factors that may surface in cases where gunshot wounds are not the obvious cause of death.

Some of these may be alleged as evidence of excessive or inappropriate physical force—neck holds, for example, and other physical control techniques that plaintiffs’ attorneys may claim induce positional or restraint asphyxia.

Others factors discussed may actually have played a decisive role in the arrest-related death at hand, but quite apart from any wrongdoing by officers. These include excited delirium and drugs such as cocaine, amphetamines, bath salts, and central nervous system depressants.

Across five chapters, nine MDs with impeccable credentials and front-line experience, including Vilke, draw on extensive research studies, case histories, and courtroom evidence to separate myth from fact regarding these subjects.

They provide investigators with specific questions to pursue to evaluate what role, if any, these elements may have played in a suspect’s sudden death. And, again, they include well-constructed checklists to document the touching of each base and to keep any legitimate possibility from being overlooked.


Two chapters dealing with non-firearm weapons round out this portion of the book.

One by Vilke and a colleague (Dr. Christian Sloane) focuses on so-called less-lethal weapons, such as riot control agents (CN and CS), OC spray, and blunt projectiles, some of which can inflict serious injuries up to death.

The authors include the history of these weapons, their mechanisms of action, their intended and other physiologic effects, safety risks, and complications, building to “the key factors to evaluate in a death investigation” where they were involved.

The second chapter, by TASER-associated Atty. Michael Brave and biomedical scientist Mark Kroll, covers conducted electrical weapons. Their writing seeks to clarify “deep misunderstandings of the basic concepts, operation, and effects” of the modern CEW that might otherwise cloud investigation of a death proximate to the use of this weaponry.

They discuss fatal falls and fume ignitions caused by CEWs and delve deeply into whether cardiac arrest from electrocution caused by this weapon is possible. (Spoiler alert: “The notion that an electrical weapon has ever electrocuted anyone is an urban myth,” they state.)

Extensive checklists accompany their chapter, including what’s important for an investigator to request of a medical examiner and what to ask witnesses, EMS personnel, and involved officers.


After a chapter on custodial deaths in detention facilities by Ross, himself a former corrections officer, Guidelines wraps up with two important topics: How to conduct an investigative interview and how to handle the media after a significant use-of-force event.

The interviewing chapter reflects the pioneering work of Force Science instructor Edward Geiselman and is co-authored with him by FS instructor Alexis Artwohl and Atty. James Wilson, a certified Force Science Analyst.

Geiselman is the co-developer of the Cognitive Interviewing technique which structures questioning to maximize the amount of memory that can be mined from an individual without compromising accuracy.

The authors explain how it works, how it differs from conventional interviewing/interrogation, and when to do it. They include revealing lessons learned for both investigators and involved officers from their professional experiences.

The book’s last chapter, “Effective Agency Response to the Media in Use-of-Force Incidents,” was written by Todd Lough, a former Chicago officer with a PhD in political science.

Among other things, he lists 10 “best recommendations for fostering effective police/media relations, especially following use-of-force incidents.”

However, he adds: “Despite an agency’s best efforts at media and public relations, there are still times when particular use-of-force incidents occur that will elicit an immediate and negative response from the press and the public. A policy of swift and aggressive damage control needs to be employed in particularly ugly situations…where there is great potential for a police department to be perceived…as either incompetent, reckless, or criminally brutal….”

As Ross tells us in Guidelines, a critical part of that damage control must be a professional, thorough, and honest investigation that helps build and sustain public trust.

Guidelines for Investigating Officer-Involved Shootings, Arrest-Related Deaths, and Deaths in Custody can be ordered through Amazon.com in both soft-cover and Kindle editions.

Darrell Ross can be reached at: dross@valdosta.edu

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