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Some California Police Departments Don’t Review Deadly Uses of Force

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Pittsburg police never investigated whether officer Ernesto Mejia's hold on Humberto Martinez, depicted here in a body camera video screenshot from Martinez's July 26, 2016 death, was appropriate, and never probed any of the other officers' actions that day. (Via Pittsburg Police Department)


ith his left arm wrapped around the neck of Humberto Martinez, Pittsburg police Officer Ernesto Mejia began to squeeze. Mejia would later testify that to subdue the struggling Martinez, he was attempting a carotid — or “sleeper” — hold designed to briefly cut off blood flow to the brain and render a person unconscious.

But the carotid arteries on either side of Martinez’s neck weren’t the only thing Mejia restricted with his execution of the difficult and controversial technique: An autopsy found he'd cut off Martinez’s breathing and fractured cartilage in his throat, causing “extensive hemorrhages.”

Martinez’s 2016 death echoes the case of Eric Garner, the New York City man whose final words, “I can’t breathe,” as a police officer choked him in 2014, became a rallying cry for a national movement opposing police use of excessive force against people of color. The Garner incident also spurred widespread debate about the danger of neck restraints.

But in Pittsburg, police never investigated how Mejia’s carotid hold had turned deadly or analyzed what Mejia and the officers with him might have done differently.

A new state transparency law, Senate Bill 1421, that’s opened internal investigation documents for the first time in decades, is providing a key insight into the long-hidden world of California policing: Not all agencies review how their officers acted — and whether they violated department policies — when they kill or badly injure someone.


Some sort of review of those incidents is set to become standard practice in California beginning in 2021, thanks to another new state law, but that legislation sets no standards for thoroughness or documentation.

KQED and the Bay Area News Group analyzed records on officers’ use of deadly force released by 122 agencies statewide, and found that 10% failed to internally investigate incidents that occurred between 2014 and 2018. The incidents included 16 fatal shootings, three deaths following fights with officers, and nine nonfatal events.

For departments that did investigate uses of force, documents show a stark range of thoroughness, from a scant single-page checklist to an in-depth analysis of whether officers followed their training, used correct tactics and employed deadly force only as a last resort. Some of the most thorough departments ordered more training and held officers accountable if they failed to follow policy.

A comprehensive analysis of the more than 500 law enforcement agencies in the state is not yet possible; some departments did not have a deadly incident during that five-year period and others have not provided relevant records.

Pittsburg Police Chief Brian Addington wouldn’t say why an internal review was never done in the Martinez case, citing a federal civil rights lawsuit over his death. Mejia didn't return messages.

Documents show Mejia was patrolling an area known for drug activity when he stopped Martinez, 36, for driving a car with expired tags on July 26, 2016. Police body-camera footage shows that Martinez bolted into a nearby home, unarmed. There, four other officers struggled to handcuff the 6’2” 285-pound man who was violently resisting them, tasing, stomping, kneeing and punching him as Mejia squeezed his neck.

After they finally cuffed him, one officer called out, “Hey, he’s going purple.” Martinez’s heart had stopped. Efforts to revive him failed. He died less than two hours later at a Concord hospital. Besides the throat injuries, an autopsy would show that the officers had broken 16 of his ribs and bruised his head and liver. It also showed Martinez had both methamphetamine and amphetamine in his system and had been drinking.

VIEWER DISCRETION ADVISED: Body-camera footage from multiple officers show Mejia struggling to subdue Martinez. This video was edited for brevity and language. Pittsburg police blurred Martinez's face before releasing footage.

That some agencies don’t document internal investigations of deadly incidents — or simply don’t do them at all — surprised some state law enforcement leaders.

“It would floor me if an agency didn't do a robust investigation” of a deadly incident involving its officers, said Ronald Lawrence, president of the California Police Chiefs Association.

A department’s procedures on such investigations reveal much about its professional standards, said Dennis Kenney, a professor at the John Jay College of Criminal Justice in New York.

A careful, well-documented probe indicates a department is serious about using force correctly and only when absolutely necessary, but the absence of records shows that some departments have a culture of “we’re going to stick our heads in the sand and hope it goes away,” Kenney said.

The lack of basic requirements for police internal investigations is reflected in reporters' findings:

• Twelve departments didn’t investigate incidents in which their officers used deadly force at all, including San Jose State University police, who didn't examine the 2014 high-profile fatal shooting of a mentally ill man, Antonio Guzman Lopez, by two of its officers. A school spokeswoman said one wasn't needed because prosecutors investigated the case and found no criminal wrongdoing. But video of the incident raised questions about whether Guzman Lopez was truly a threat to officers.


• Three departments — Orland, Dixon and Suisun City — said they lost records of their policy findings regarding a shooting.

• Avenal police in Kings County created internal review documents 11 days after receiving the news agencies’ request for the missing records related to two 2017 deadly shootings. The police chief declined to explain his department’s internal investigation protocols. Both incidents were found to be “in policy.”

• One hundred and five departments did some kind of review, but many showed no documented analysis or recommendations. For example, Yreka police in Siskiyou County “did not follow the standard (internal affairs) procedure” when officers fatally shot a man because “no citizens complaint was ever filed” and no allegations of wrongdoing were brought, a captain wrote to the department’s chief. “No questions were ever asked by the Yreka Police Department.”

A spokeswoman for California’s Commission on Peace Officer Standards and Training wrote in an email that police departments aren’t required by law to look at deadly incidents, but they’d “be exposed to tremendous liability” by failing to do so.

Regardless of the lack of a mandate, police trainer Gary Gregson, who spent seven of his 30 years as a Sacramento officer working in internal affairs, said every agency should examine what cops might have done wrong.

“The whole process is not only about managing risk and liability; it's an opportunity for the organization to make itself better," he said.

For example, if Pittsburg police had investigated Martinez's death, they might have raised questions about whether Mejia understood the hold he tried to use.

“I put him in a chokehold," Mejia said to his supervising sergeant as medical personnel tried to revive Martinez, body-camera video shows.

But Sgt. James Terry was quick to suggest a different term: “In the carotid.”

“In the carotid,” Mejia repeated.

Those terms have very different meanings, said Jim Boydd, a former police officer who now trains cops on how to safely use what's often called a “carotid hold” or “sleeper hold,” although Boydd’s preferred term is a “vascular neck restraint.” In that hold, an officer applies pressure to arteries on the sides of the neck, restricting blood flow to the brain, causing the person to pass out. It is not considered deadly force because it’s intended only to restrain a suspect, not kill them.

Boydd wouldn't comment on specific cases but said if done correctly, the carotid hold doesn't block the airway. “The person has to maintain the ability to breathe, obviously,” he said.

(Jeff Durham/Bay Area News Group)

A chokehold does the opposite, applying direct pressure to the front of the throat, Boydd said, and cutting off breathing. That hold can be deadly and isn’t supposed to be used unless an officer’s life is in immediate danger.

The doctor who performed Martinez's autopsy testified in court that the man's airway was obstructed for four to six minutes.

Michael Haddad, a lawyer for Martinez’s family, said in an interview he suspects Pittsburg didn’t investigate because police feared a finding that Mejia broke use-of-force rules could be used in a lawsuit. He said the department's failure to properly train officers in the risky technique amounts to deliberate indifference. And, he said, the department can't correct mistakes if it doesn't look for them.

“They seem to be making no effort to try to prevent something similar from happening to someone else,” Haddad said.

Pittsburg’s attorneys argued in court documents that Mejia properly applied the carotid hold and pointed to Martinez’s drug use and weight as contributing factors in his death.

Martinez’s death wasn’t the only one attributed to suffocation by a cop, news organizations found.

In 2016, Wendell Celestine, 37, died during a violent struggle with Antioch police officers Mark Moraga and Michael Mortimer. The officers were trying to arrest Celestine, who had a history of grand theft, robbery and drug crimes dating to 1996, for a parole violation.

Records of the incident released under SB 1421 state that Mortimer hit Celestine repeatedly with a flashlight. Moraga used a carotid hold until Celestine passed out. He regained consciousness and began struggling as the cops tried to place him in a restraint device. Then Celestine stopped breathing. The coroner found his death was caused by “mechanical obstruction of respiration (‘suffocation’)” due to “carotid restraint hold by police while resisting arrest.”

Wendell Celestine, 37, died during a violent struggle with Antioch police officers Mark Moraga and Michael Mortimer in 2016. (Via Antioch Police Department)

The records did not include evidence that the department ever conducted a use-of-force review. Antioch Police Chief Tammany Brooks said in an email that his department does “review” deadly incidents, but doesn’t document any findings unless it receives a formal complaint or investigators think a policy might have been violated. Celestine’s asphyxiation death didn't prompt such an investigation, nor did eight shootings by Antioch cops from 2014 to 2018, he said.

Brooks at first agreed to an interview but then decided to postpone indefinitely. He wrote in an email that he “recalled a number of our policies are currently undergoing review and updates, including policies potentially involved with this topic.”

Pittsburg police have since changed their policies; the department now reviews all deadly-force incidents and documents findings. Addington said in “the vast majority of the cases we identify something that we could maybe look at differently.”

Before this policy change, Pittsburg, like most of the other agencies found to lack internal investigations, simply relied on criminal investigations done by the county district attorney.

For example, when police in the Monterey County town of Marina were asked for investigative records of a deadly 2015 shooting, they responded by email that internal investigations are “conducted by the District Attorney’s Office,” not the police department.

But prosecutors have a different focus: whether an officer committed a crime.

Then-Monterey County Assistant District Attorney Anne Michaels made that clear in the report she wrote on the 2015 Marina shooting: The DA’s scope “is not to advise best practices for law enforcement in the field, but rather to determine whether any officer committed a crime beyond a reasonable doubt.” She found the Marina officer was legally justified when he shot and killed a man who’d just stabbed his wife.

But even a legally justified shooting can provide vital tactical lessons, said former internal affairs investigator Gregson. Sometimes it’s learning how deadly force might have been avoided, or identifying what went right.

Telling officers fresh from a violent situation that they made good decisions can be “huge” for them, Gregson said, and is “an important thing for officers to be able to hear.”

Sam Walker, an emeritus professor of criminal justice at the University of Nebraska Omaha, said California’s move toward transparency will help bring it into an era of more modern policing, one where “proactive departments will get answers and solve problems,” he said, such as: “Are there bad cops? Are there bad policies?”

Documents released so far under SB 1421 show departments that ask those questions sometimes find serious training issues and address them.

In a 2016 incident, Daly City Officer Peter Nelson shot and wounded a domestic violence suspect who was stabbing himself with a pen. The officer was at first publicly commended for his actions, but documents show he was later formally reprimanded for violating department policy by trying to shoot the pen out of the man’s hand.

In 2017, Officer Andrew Van Woerkom of the El Cajon Police Department in San Diego County was among a group of officers who responded to a suicidal man holding a knife. One of the other officers had a bean-bag gun, giving police a less-lethal option to subdue him.

Instead, Van Woerkom shot and wounded the man.

“There were two sergeants on scene and clearly, neither expected Van Woerkom to use deadly force,” a captain later wrote of the officer’s actions.

In its post-incident review, the department found the shooting complied with policy because Van Woerkom said he thought the man posed a deadly threat, according to records obtained by the Los Angeles Times.

But an investigator also recommended Van Woerkom receive specific training in decision-making and de-escalation. All the department's officers received additional training on less-lethal options, dealing with suicidal people, and clearer communication.

In the future, California police departments will not have a choice of whether to investigate deadly force. A new law, Senate Bill 230, that law enforcement groups backed, requires agencies to review all instances when an officer discharges a firearm and have a policy outlining factors to examine anytime an officer uses force. The law goes into effect Jan. 1, but most of its requirements aren’t effective until 2021.

Lawrence, of the state Police Chiefs Association, said he's hopeful the new law will help standardize police policies and documentation around use-of-force investigations. But without benchmarks that define what a thorough “review” must look like, it is unclear what will actually change. And Lawrence said he and other police leaders don’t even have a good idea of what most agencies are doing right now.

"The truth of the matter is we don't know," he said.

Nate Gartrell and Robert Salonga of the Bay Area News Group contributed to this story.

This story was produced by the California Reporting Project, a coalition of 40 news organizations across the state. The project was formed to request and report on previously secret records of police misconduct and use of force in California.

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