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Review of the In-Custody Death of Michael Marshall Concludes


DENVER – Today the Denver Department of Safety announced that two deputies and a watch commander involved in the in-custody death of Mr. Marshall will be disciplined for violating department policies and procedures.

“The tragic death of Mr. Marshall and the time it has taken to complete a thorough review of the incident has been difficult for his loved ones and for everyone involved,” said Executive Director of Safety Stephanie O’Malley. “The Sheriff Department takes its charge to ensure the safety and security of Denver’s jails seriously, and when someone dies, the entire department, family members, and the greater community feel the gravity of the tragic outcome. After conducting a full review of the incident and considering the facts and circumstances of the case, it has been determined that three of the employees associated with the incident violated rules and regulations. As such, discipline is appropriate and has been imposed.”

Multiple agencies participated in a thorough and impartial review of the incident, including an independent investigation by the Denver District Attorney’s Office, a Denver Sheriff Department Internal Affairs Bureau review, a review by the Conduct Review Office of the Denver Sheriff Department, an independent review by the Office of the Independent Monitor, and an independent review by the Executive Director of Safety’s Office.

Click here to view the detailed orders of discipline issued to the deputies. Below is a summary of the incident and the related reviews and findings. 

On November 7, 2015, Mr. Marshall was booked in to the Downtown Detention Center and assigned to a special management housing unit. On November 9, 2015, according to medical personnel, Mr. Marshall was behaving in a manic and erratic manner.

On November 11, 2015, Mr. Marshall continued to demonstrate erratic behavior. This behavior continued while he was permitted out of his cell for free time and aggressively approached another inmate. Deputy Arellano and Deputy Hernandez intervened, and Mr. Marshall was escorted to a nearby sally port area away from the other inmates.

While Mr. Marshall was in the sally port, Deputy Arellano telephoned Nurse Allison to inform her of Mr. Marshall’s erratic behavior and to request that Mr. Marshall be evaluated. Deputy Arellano also requested a change in Mr. Marshall’s classification level that would have allowed Mr. Marshall to be moved to a housing assignment with a camera cell, so that deputies could better monitor his behavior. Nurse Allison then contacted the Psych Emergency Department to obtain authorization for the reclassification and to obtain a prescription for emergency medication for Mr. Marshall.

While the nurse called to obtain authorization for the change, Deputy Garegnani entered the sally port area where Mr. Marshall was sitting on a bench and stood in front of the door. Deputy Hernandez was also in the sally port area to Mr. Marshall’s right, and Deputy Civic and Deputy Phuvapaisalkij were in the hallway outside of the open sally port door.

Less than one minute after Deputy Garegnani entered the sally port area, Mr. Marshall got up from the bench and attempted to walk past the deputy and through the sally port door into the secure corridor. Deputy Garegnani stopped Mr. Marshall and directed him to sit back on the bench. Mr. Marshall continued his attempt to exit the sally port area and Deputy Garegnani placed his hand on Mr. Marshall’s chest and pushed him away to create distance and to stop Mr. Marshall from moving forward into the secure corridor. After Deputy Garegnani pushed Mr. Marshall away, Mr. Marshall’s back was against the wall and he began to slide sideways along the wall down to the ground.

Deputy Garegnani grabbed Mr. Marshall’s upper arm to prevent him from falling to the ground and to place him back on the bench. As this was happening, Deputy Civic and Deputy Phuvapaisalkij entered the sally port from the hallway and Deputy Hernandez also moved to assist Deputy Garegnani. The deputies attempted to place Mr. Marshall back on the bench; however, his body leaned forward and he and the deputies went to the ground, where the deputies struggled to gain control of Mr. Marshall.

After multiple verbal commands and attempts to gain control were unsuccessful, Deputy Garegnani called for officer assistance. Deputies made additional attempts to gain control of Mr. Marshall by applying pressure and securing his appendages; however, Mr. Marshall continued to struggle with the deputies. Mr. Marshall was eventually handcuffed and leg iron restraints were applied to his ankles.

Once the deputies gained sufficient control of Mr. Marshall they attempted to help him to his feet but he became limp and unresponsive. The deputies laid Mr. Marshall back down and turned him on his side, and Deputy Garegnani tried to revive Mr. Marshall by performing a sternum rub. When Mr. Marshall remained unresponsive, and deputies noticed he had vomited, immediate nurse assistance was requested for a medical emergency. 

As the nurses started to arrive, Mr. Marshall came to and began to struggle again. Deputies were still restraining Mr. Marshall by his appendages.

When the nurses began to assess Mr. Marshall, they observed that he had vomited but had airflow and was breathing.  Nurse Allison listened to Mr. Marshall’s lungs and detected bronchial spasms. She instructed the deputies to hold Mr. Marshall by his extremities and ensure that there was no pressure on his shoulders or back. Nurse Allison also told the deputies that Mr. Marshall needed to be placed in a seated position in order for her to assess his lungs better. While deputies were waiting for the restraint chair, the deputies continued to restrain Mr. Marshall. They also placed a spit hood over his head to prevent him from biting or expelling bodily fluid, including vomit, onto the deputies.

When the restraint chair arrived, the deputies secured Mr. Marshall into the chair and moved it from the sally port into the corridor. During this time, Mr. Marshall’s head lolled and he slumped to the side. Deputy Civic performed a sternum rub but Mr. Marshall was once more unresponsive. The nurses began to assess Mr. Marshall and determined that he was not breathing. The deputies removed the restraint straps and lifted Mr. Marshall to the ground. 911 was called and lifesaving measures began.

A paramedic arrived and determined that Mr. Marshall had no electrical activity in his heart.  An attempt was made to place an intubation tube in Mr. Marshall’s throat but the paramedic was unable to intubate Mr. Marshall due to excess vomit in his airway. The paramedics also gave Mr. Marshall a dose of Epinephrine.

After lifesaving measures were attempted, including approximately 20 minutes of CPR, paramedics detected a pulse and Mr. Marshall was transported to Denver Health Medical Center (DHMC).  Mr. Marshall was in a comatose state at DHMC for nine days before he passed away on November 20, 2015.

An autopsy was performed on November 21, 2015 and the autopsy report was released on January 8, 2016. The report indicated that Mr. Marshall died from positional asphyxia to include aspiration pneumonia with contributing factors of chronic heart disease and chronic lung disease.

Following the incident, the Denver District Attorney’s Office conducted an investigation to determine if the deputies’ actions warranted criminal charges. On January 21, 2016, Denver District Attorney Mitch Morrissey issued his Decision Letter, stating that no criminal charges would be filed against the deputies. Mr. Morrissey concluded that the physical force the deputies used was not intended to harm Mr. Marshall but was applied for the lawful purpose of maintaining order and providing safety and security in the jail. 

After the District Attorney’s Office issued its letter, the Internal Affairs Bureau (IAB) of the Denver Sheriff Department initiated a separate, internal investigation on January 26, 2016. On February 25, 2016, IAB sent its investigation to the Office of the Independent Monitor (OIM).

On March 4, 2016, the OIM requested that IAB conduct further investigation and interviews, which included involvement from Denver Health Medical Center (DHMC) staff.

IAB completed the additional investigation requested by the OIM on April 4, 2016, except for the portions that involved DHMC staff. Responses to the additional questions that were sent to DHMC staff were sent to IAB on July 27, 2016.

On August 4, 2016, IAB sent its investigation to the Conduct Review Office (CRO) of the Denver Sheriff Department for its review of potential rule and regulation violations. The CRO reviewed the entire case file and completed its analysis on November 15, 2016. The CRO findings were presented to Sheriff Firman on January 23, 2017.

Seven subject officers received contemplation of discipline letters on March 7, 2017 that set out the policies that may or may not have been violated by their individual actions. Pre-disciplinary meetings for each subject deputy where held from March 21, 2017 – April 5, 2017 to afford the deputies an opportunity to respond to the contemplation of discipline letters.

After considering the information presented at the contemplation of discipline meetings, the IAB investigation, and the CRO findings, Sheriff Firman and the OIM advanced recommendations to the Executive Director of Safety’s Office for its consideration.

On April 17, 2017, the Executive Director of Safety’s Office completed its review of the entire case file and determined that disciplinary action against three of the subject deputies was warranted. As a result, two deputies and the watch commander were each issued suspensions ranging from 10 to 16 days. The employees may appeal their suspensions to the Career Service Hearing Office within 15 calendar days.

The Denver Sheriff Department recognizes the need to continually assess how it approaches mental health considerations in its jails. For over a year now, the department has provided Crisis Intervention Training (CIT) and Mental Health First Aid training to employees. Last year, the department also completed its new use of force policy, which emphasizes the need for deputies to de-escalate situations as an alternative to force whenever possible. The Sheriff Department also has a Transition Unit at the County Jail that provides intense wraparound services to inmates with mental health needs.

Importantly, the department is also working with other stakeholders to address mental health concerns from a broader perspective. The Justice Coordinating Committee (JCC) is working with the department to divert individuals with mental health issues from jail and into support services when appropriate. The JCC is comprised of city and state justice and corrections leadership who have a role in the criminal justice system. Denver’s Office of Behavioral Health Strategies is also working with the sheriff department to provide mental health clinical support in the Downtown Detention Center. These mental health responders will work with Denver Health psychology staff within the facility to provide proactive support to inmates who are struggling with mental health concerns. They will also support deputies in responding to incidents inside Denver’s jails.