Two officers stood on Fernando Rodriguez’s outstretched arms, handcuffs connecting his wrists. Another stood on the shackles binding the 24-year-old’s legs. A fourth officer kneeled on Rodriguez’s back. The fifth placed his weight on the man’s buttocks.

Five officers from the Hampton city and Henry County police departments in Georgia subdued Rodriguez late on Sept. 20, 2019, after receiving multiple calls about a nude man walking down a blacktop road. The details of what happened are revealed in court documents, police and autopsy reports and officer body-camera footage reviewed by the Howard Center for Investigative Journalism at Arizona State University.

Police accounts describe a violent struggle with Rodriguez, who was reported acting erratically and possibly on drugs, involving at least nine Taser shocks. Body-camera video and audio paint a fuller picture of what happened, including that Rodriguez was shocked at least 16 times during the incident.

As officers arrived on the scene, Rodriguez ignored orders to get on his stomach on the ground and continued walking away. An officer fired his Taser in an attempt to get Rodriguez facedown on the ground in what’s known as a prone position. “Hit him again,” one officer said, referring to the Taser. “Somebody sit on him; sit on him y’all,” another commanded.

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With five officers holding down various parts of his body, Rodriguez lay on his stomach with his wrists and ankles shackled for nearly 10 minutes before an officer questioned whether he was still breathing. “He’s holding his breath,” another replied.

“I just didn’t want to have to beat the boy to death. That’s what happened to the last one we did,” one officer said as they waited for paramedics.

After crying out in the prone position several times, Rodriguez was quiet and still by the time medics arrived. One of the officers standing on him said: “He’s playing possum right now.”

Widely accepted best practices say officers should promptly move someone off their stomach once handcuffed. However, more than 13 minutes elapsed after Rodriguez was wrestled into the prone position and when paramedics rolled him onto his back, body-camera video shows. Rodriguez was rushed to the hospital, where staff thought he’d been run over by a car because of what looked like “tire tread tracks” on his arms. He died three days later.

A county coroner ruled his death a homicide caused by asphyxia due to physical restraint in the prone position with compression of the chest. Another significant condition listed was LSD use.

For decades, top law enforcement agencies have warned that certain restraint techniques may hinder someone’s ability to breathe and increase their risk of death, particularly in people who are unhealthy and those under the influence of drugs. But a lack of standardization in policing and mixed messages from the law enforcement and medical communities have led to contradictory policies on officer training.

An investigation by ASU’s Howard Center, in collaboration with The Associated Press, found 60 other cases similar to Rodriguez’s, in which a medical official cited positional asphyxia – when someone’s physical position means they cannot breathe properly -- or prone restraint as causing or contributing to a death. Those deaths took place from 2012 through 2021.

At least two states, Washington and California, have attempted to curtail the use of prone restraint in recent police reform laws, even as cities pay millions of dollars in settlements to victims’ families.

Rodriguez’s family sued the city of Hampton, Henry County and the five officers in May 2021, arguing that police used excessive force and that officers’ training was to blame. The city of Hampton and Rodriguez’s family settled the federal lawsuit for $3 million. A lawsuit against two of the Henry County police officers was settled for an undisclosed amount. Attorneys representing the city and county did not respond to a request for comment.

BROAD AGREEMENT

In 1993, the International Association of Chiefs of Police advised that officers should avoid tactics that increase the risk of positional asphyxia, such as applying pressure for an extended period of time, keeping suspects on their stomach or transporting someone in a hogtie position – when the ankles and wrists are handcuffed, then bound together behind the person’s back. Two years later, the U.S. Justice Department said “maximal” prone restraint techniques such as hogtying should be avoided.

The FBI warned in 2006 of the dangers of positional asphyxia and advised law enforcement to avoid restraint techniques that restrict breathing. Five years later, the nonprofit Police Executive Research Forum, which specializes in law enforcement research and policy development, acknowledged the risks of positional asphyxia, especially after officers shock someone with a Taser.

The danger of prolonged prone restraint is “one of the relatively few areas in policing where there is as close to universal agreement as it is possible to have,” said Seth Stoughton, a law and criminology professor at University of South Carolina. “In the training environment, I would say it is, if not universally acknowledged, it is the next best thing to universally acknowledged.”

But because the U.S. Constitution limits the power of the federal government to regulate state and local governments in areas such as policing, local law enforcement agencies are able to develop their own policy and training manuals.

A decades-long debate in the medical community over the dangers of prone restraint has contributed to the mixed messages.

In the late 1980s, pathologist Donald Reay and co-authors from the University of Washington concluded that positional restraint should be recognized in deaths when a person is “prone, handcuffed and hog-tied.” A group of University of California San Diego researchers challenged that conclusion in 1997, saying prone restraint did not result in a “clinically relevant” impact on breathing among healthy young subjects.

A year later, Thomas Neuman of the University of California San Diego said he found that hogtying did not cause positional asphyxia. The National Institute of Justice, the Justice Department’s research arm, cited that study and encouraged law enforcement agencies to evaluate their policies “in light of these new findings.”

However, in July 2022, a team of pathologists and cardiologists writing in the Journal of Forensic Sciences posited that prone restraint can lead to “prone restraint cardiac arrest,” rather than asphyxia. They said the San Diego study and others like it did not consider the “real-world stress conditions” that come with restraint tactics.

CONTRADICTORY TRAINING

Many states set minimum training requirements for agencies. However, the Howard Center found multiple agencies with policies that contradicted these minimum requirements, including the Henry County Police Department in Georgia.

Then-Henry County Police Chief Mark Amerman testified in Rodriguez’s lawsuit that, to his knowledge, the department’s officers did not receive training on how to put a suspect in a prone position or on positional asphyxia.

At the time of Rodriguez’s death, the Henry County Police Department’s lack of training conflicted with the Georgia Law Enforcement Certification program’s January 2019 standards manual, which said agencies shall have written guidance on restraining devices and methods. Techniques that could lead to positional asphyxia should be prohibited, it advised.

Amerman also said the department never saw anyone have complications of positional asphyxia or prone restraint. However, records show in 2016 two Henry County police officers were involved in the death of Jackie Weems Jr., who lost consciousness while being held in prone position. It wasn’t until the officers moved Weems into a seated position that they realized he stopped breathing, according to a criminal investigation report.

Michael White, an Arizona State University professor and co-director of a Justice Department program to help law enforcement agencies with body-worn cameras, said policy is effective only if it is understood and enforced.

“Without enforcement, a policy is just a piece of paper,” White said in an email. “With enforcement, a policy is the centerpiece of accountability.”

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Reporter Taylor Stevens contributed to this story, which was produced by the Howard Center for Investigative Journalism at Arizona State University’s Walter Cronkite School of Journalism and Mass Communication. The Howard Center is an initiative of the Scripps Howard Fund in honor of the late news industry executive and pioneer Roy W. Howard. Contact us at [email protected] or on X (formerly Twitter) @HowardCenterASU.